Breast MRI Indications 2014 !

Sophie Taïeb, Luc Ceugnart – Centre Oscar Lambret – Lille

MRI = Poor specificity

Ø  44 studies. 1985 – 2005. 3101 pts,

Ø Se : 90% [0.88-0.92]

Ø Sp : 72% [0.67-0.77]

Ø  69 studies. 1985 – 2010. 9298 pts, 9884 lesions.

Ø Se : 90% [0.88-0.92]

Ø Sp : 75% [0.70-0.79]

Ø  LR+ : 3,64 [3-4,2] Ø  LR- : 0,12 [0.09-0.15]

Ø AUC : 0.91 Ø  Point Q* : 0.84

MRI = Poor specificity Medeiros LR et al. Breast Cancer Research andTreatment 2011

False negative lesions Late enhancement

Ø  5 % of cancers ü  DCIS. Kuhl et al. Lancet 2007 : 44/89/7139 DCIS high grade

ü  Well differentiated carcinomas : Mucinous ü  LIC ü  Fibrous carcinoma Utility of a late sequence (> 8 mn)

False positive lesions   Benign lesions with early enhancement

Ø  Focal enhancement ü  Normal breast (1st week or 2nd part of cycle) ü  Young fibroadenomas ü  Intra breast lymph nodes ü  Fat necrosis ü  Radial scar ü  Proliferative mastopathy with cysts ü  Phyllodes tumor(grade 1) ü  Post surgery (6 mois) ü  Post biopsy

Ø  Diffuse enhancement ü  Normal breast (1st week or 2nd part of cycle) ü  Hormonal replacement therapy – OC – Mirena IUD ü  Proliferative mastopathy with cysts ü Inflammatory breast ü Post radiation therapy

False positive lesions   Benign lesions with early enhancement

Ø  Perform in specialist breast units with experience in CI ü At least 150 MRI / year / centre ü MRI biopsy in house or agreement with another institution

Ø Use adequat sequences in adequat period of menstrual cycle (7-12)

Use adequat sequences

Ø  Dedicated breast coil, Bilateral acquisition, 2nd week of cycle Ø  At least one unenhanced high-contrast sequence (T2 FSE) Ø  2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness < 4mm,

each sequences < 120 sec. At least 8 mn. Ø  Gadolinium-chelates 0,1mmol/kg – 2-3ml/s, saline flush

(20-30ml)

Ø  Post processing : temporal substraction, dynamic analysis MIP

Ø  Not yet assessed in routine practice (2010) : DWI-MRI and H+ Spectroscopy

Ø  Perform in specialist breast units with experience in CI ü At least 150 MRI / year / centre ü MRI biopsy in house or agreement with another institution

Ø Use adequat sequences in adequat period of menstrual cycle (7-12)

Ø Use Birads lexicon to describe lesions

Ø Respect indications

F  A measure of the level of evidence (LoE) from 1a (highest) to 5 (lowest)

F  Degree of recommendation (DoR) from A to D, F  Clinical recommendations not based on scientific evidence were

explicitly labelled as experts panel opinions (EPO).

Respect indications

Ø  LoE 1,2 ; DoR A,B ü  No MRI ü  MRI first ü  MRI to specify CI

LoE-1A, DoR-A

1 - No MRI when biopsy can be performed

Ø  Birads 3, 4 ou 5 Targets with CI = biopsy ü  Calcifications = vacuum assisted breast biopsy ü  Nodules = core needle biopsy or VABB

MRI if biopsy not feasable or if discordance between image and VABB (EPO)

2 - No MRI in Young women, with risk < 20-30% for

all life, especially with dense breasts and especially if anxious.

MRI first in screening of high-risk women Ø Annual MRI : EPO Ø Assessment screening program : recall rate < 10% EPO Ø  Begin at 30-year-old : LoE-2b, DoR-B

Dr L.Ollivier

MRI to specify CI : Ø  Evaluation of response to neoajuvant chemotherapy. §  If perform : Pretreatment MRI always. LoE-1b; DoR-A §  Very low enhancement after ttt is a sign of residual

lesion : LoE1, DoRA §  In poor reponders based on clinical examination and CI

no MRI is not useful. EPO

MRI to specify CI : Ø  Evaluation of response to neoajuvant chemotherapy. (LoE-1b;

DoR-A) Ø  Breast cancer recurrence (LoE-1b; DoR-A)

ü  Difficult Clinical examination, CI and Biopsy ü  BUT

*  No screening by MRI *  MRI after CI + Biopsy (if target)

ü  No FP after RT ü  FN occur

1953 2001 : LIC Left breast : BCT 2003 : Mass Biopsy : Normal breast

1953 2001 : LIC Left breast : BCT 2003 : Mass Biopsy : Normal breast MRI : Fat necrosis : Birads 2 Follow-up : no recurrence

MRI to specify CI : Ø  Evaluation of response to neoajuvant chemotherapy. (LoE-1b; DoR-

A) . Ø  Breast cancer recurrence. (LoE-1b; DoR-A) Ø Occult breast cancer (LoE-1b; DoR-A)

ü  Not indicated in extensive metastatic disease (EPO) ü  If MRI negative avoided surgical treatment of

ipsilateral breast (LoE-2b; DoR-B)

63-year-old, Left axillary lymph node Ø  LIC Ø  Negative CI

T2 MIP first Sub

§  Mass 6mm §  Birads 4 : round,

irregular margins, Curve type 3

§  Left lymph node : CLI

§  R : CCI + CCIS + LN

MRI to specify CI : Ø  Evaluation of response to neoajuvant chemotherapy. (LoE-1b; DoR-

A) . Ø  Breast cancer recurrence. (LoE-1b; DoR-A) Ø  Occult breast cancer (LoE-1b; DoR-A) Ø  Breast implants: augmentation or reconstruction

ü  MRI is not a screening tool (LoE-1, DoR-A) ü  Implant rupture ? Non contrast MRI (LoE-1a, DoR-

A) ü  Recurrence ? Contrast-enhancement MRI (LoE-2,

Dor-B)

Breast implant rupture

Breast implant capsule

Breast implant wall

Intracapsular Rupture

Extracapsular rupture

Courtesy Dr C.Balleyguier - IGR

Intra capsular rupture

Extra capsular rupture

Courtesy Dr C.Balleyguier - IGR

§  56 year-old §  Breast reconstruction 3 years ago §  Direct trauma (Fall off a bike) §  US : Intracapsular rupture ?

MRI

Silicone breast implant MRI = Intracapsulare rupture

T1

T2

STIR

Silicone breast implant MRI = Intracapsulare rupture

T1

T2

STIR

T2

Water & Fat sat

Respect indications

Ø  LoE 1,2 ; DoR A,B ü  No MRI when biopsy can be performed. Young women ü  MRI first : Screening of high-risk women ü  MRI to specify CI : Evaluation of response to neoajuvant

chemotherapy, Breast cancer recurrence, Breast implants, Occult primary breast cancer.

Respect indications

Ø  LoE 1,2 ; DoR A,B ü  No MRI when biopsy can be performed. Young women ü  MRI first : Screening of high-risk women ü  MRI to specify CI : Evaluation of response to neoajuvant

chemotherapy, Breast cancer recurrence, Breast implants, Occult primary breast cancer

Ø  LoE = 3 – EPO : All MRI as « problèmes solving » : Nipple discharge, Paget disease, AD seen on one incidence…

MRI allows to highlight carcinoma not seen on CI J

§  46 year-old §  Paget disease §  CI : negative

MRI

§  46 year-old §  Paget disease §  CI : negative

§  MRI : 2 biopsies IDC, DCIS

§  P : DCI + comedo carcinoma, 1N+ (GS), GSBR 7, Ki67 35%, RE+, RP-, Her2+

41 y-o - Nurse Normal physical examination Mother with breast carcinoma under 50 years-old 1st mammography

US : no lesions seen

BiRads 3 or MRI ?

BiRads 2

MRI = PROBLEM SOLVING J

CONTRALATERAL BREAST

3rd sequence postC T2FS

Ø  BiRads 3 Ø  US : not seen

Washin card

Follow up 4 months : Persistence of lesion Biopsy

Failure

2 Months later : SURGERY MRI wire localization

ü HYPERPLASIA without atypical cells

MRI = Problem creating L

Respect indications

Ø  LoE 1,2 ; DoR A,B ü  No MRI when biopsy can be performed. Young women ü  MRI first : Screening of high-risk women ü  MRI to specify CI : Evaluation of response to neoajuvant

chemotherapy, Breast cancer recurrence, Breast implants, Occult primary breast cancer

Ø  LoE 2–DoR=B : Staging before treatment planning Ø  LoE = 3 – EPO : All MRI as « problèmes solving » : Nipple discharge, Paget disease, AD on one incidence…

Staging before treatment planning

Change of treatment planning due to MRI : à Biopsy of additional lesions +++ to avoided

mastectomy due to FP - LoE-1a, DoR-A

(5) – Breast cancer in women < 40 ans

Ø  If MRI = more TM & thus increase overall survival : this is good news

Ø  M.Morrow ( Editorial JAMA 2004)

Technological breakthrough = Go back to 70’ for

treatment.

Staging before treatment planning

Patientes randomisées entre 1975 et 1985

Ø  50 / 237 – 1996-2011 Ø  10811 pts Ø MRI :

ü  20% ipsilat. lesions more: PPV 59 à 74% à biopsies §  Wider excision in 12,8% but 6,3% useless §  Local recurrences rate after BCT : 0.5-1% per year

ü  5,5% contralat : PPV 27 à 47% à biopsies

Ø Patients outcome ??

à 01/2013 Ø  4 studies – 3169 pts, 3180 lesions Ø  1833 no MRI, 1347 MRI. 1 randomized (COMICE), 3 no Ø Median follow-up 2.9 years [1.6-4.5]

ü  64/3169 local recurrences (2%) MRI : 1.8%; No MRI : 2.2% NS

ü  93/2708 distant recurrences (3.4%)

8-year probability : §  LR-free survival for MRI : 97% [95-98] vs no MRI = 95% [93-97] P=.87 §  DR-free survival for MRI : 89% [83-93] vs no MRI = 93% [90-95] P =.37

Ø  Preoperative MRI in routine staging does not reduce the risk of LR or DR

Ø Study limitations : ü Only 4 studies ü Only 1 randomized ü Only 8 years probability follow-up ü Contralateral breast : no information

Staging before treatment planning

Change of treatment planning due to MRI : à Biopsy of additional lesions +++ to avoided

mastectomy due to FP - LoE-1a, DoR-A

(5) – Breast cancer in women < 40 ans

Ø  LoE 1,2 ; DoR A,B ü  No MRI when biopsy can be performed. Young women ü  MRI first : Screening of high-risk women ü  MRI to precise CI : Breast cancer recurrence, breast

implants, Occult primary breast cancer, Evaluation of response to neoajuvant chemotherapy .

Ø  LoE = 2 – DoR=B : Staging before treatment

planning Invasive LC, High-risk patients, discrepancy in size between

mammo and US with expected impact on treatment decision

Ø  LoE = 3 – EPO : All MRI as « problemes solving » : Nipple discharge, Paget disease, AD on one incidence… MRI as problemes creating…

In summary

Key points

1.  Respect indications – Poor specificity !! 2.  Respect technical conditions 3.  Use BiRads lexicon (allowed Birads 0) No more problems after MRI than before

ü  Explain it to patients ü  Explain it to referent colleagues And do it BEFORE to perform Breast MRI