Breast MRI BREAST MRI - ISRRT

1920Enhancing Breast CancerFeatures of Breast Malignancy:MorphologyKineticsCourtesy: Dr. Bruce Porter2122BI-RADSGrading BI-RADS ®•Published by ACR•Mammography•Ultrasound•MRI•0 - Incomplete exam•1 - Normal•2 - Benign•3 - Probably Benign•4 – Probably Malignant•5 – Malignant•6 – Biopsy ProvenCancer• 1 Normal Benign• 2 Benign• 3 Probably Benign Imaging follow up or tissue• 4 Probably Malignant TISSUE• 5 Malignant TISSUEBI-RADS MRI Scoring23MRI Scoring System (Gottingen score)24•MRI Artefact Category•Density Type•1-4•1-4Points 0 1 2Shape -Margins Well -defined Poorly definedContrast Homogenous Inhomogeneous RingInitial Inc 100%Post Initial Increase Plateau Washout

3132MRI Breast ScreeningMRI Breast Screening• Sensitivity• Clinical 17.9• Mammography 33.3• MRI 79.5• Specificity• Clinical 98.1• Mammography 95.0• MRI 79.53334American Cancer Society Guidelines forBreast Screening with MRI as an Adjunctto Mammography• March 2007• Screening MRI is recommended:• for women with an approximately 20–25% or greater lifetimerisk of breast cancer,• including women with a strong family history of breast orovarian cancer and• women who were treated for Hodgkin disease.Non-Screening Clinical Indications for ContrastBreast MR• Lobular Cancer• Occult Breast Cancer• Close or positive surgical margins• Post-operative scar vs. tumor recurrence• Neo-adjuvant chemotherapy or brachytherapy• Suspected multiple or bilateral cancers• Implants and known or suspected cancer• Problematic Mammogram• Assessment of all diagnosed breast cancers.3536MRI in unilateral breast cancerMRI in diagnosed breast cancer• NEMJ March 2007• 969 with diagnosis of unilateral breast cancer• Other breast normal clinically and mammo• Occult cancer in second breast 3.1%• April 2008• European Breast Cancer Conference in Germany• 249 patients who had malignancy on biopsy had MRI• Altered management in 13%• 20 additional cancers – 8%• Better than mammo or US in assessing tumour size• “We would like to see MRI become a standard preoperativetreatment for breast cancer, along with biopsy,mammography, and ultrasound”

37 38Analysis3940Unilateral vs. Bilateral• Cancers arebilateral in up to10%Multiple lesionsInfiltrating ductal CaFibroadenoma• Exclusion ofcontra-lateral tumoris of great clinicaland personal valueCourtesy: Dr. Bruce PorterCourtesy of FHDI4142DCIS

4950Contrast-enhanced Breast MR: AccuracyStaging• Varies significantly with technique and experience.• Sensitivity: > 94 – 98 %• Negative Predictive Value: > 95 %• Specificity: 37 – 97 %• Positive Predictive Value: ~ 65- 75 %• For DCIS sensitivity is lower, especially for low orintermediate grades; also for some lobular, low grade, orless angiogenic invasive carcinomas.Courtesy: Dr. Bruce Porter5152Chest STIR: Aids in cancer stagingMR - guided breast biopsies• Look for highest positive lymph node• Use body coil, supine placement• Some lesions are not visible with mammography orultrasound (US)• After identified with MR (diagnosis)• Many lesions can be found using US• US is interactive, cheaper, faster• MR-guided BB needed for those lesions which cannot be seenin retrospect on US or mammaographyCourtesy of FHDI5354MRI Breast Biopsy DeviceBreast Biopsy• Lateral and medial access• Needle or wire placement(core, fna)• Vacuum assisted biopsyextraction• Software controlledguidance• Comfortable patientsupport

5556Spectroscopy - MRSMRS monitoring of Chemotherapy• Early results show specificity• > 95%• Choline peak at 3.6 ppm• Single voxel studiesBeforeChemotherapy1 stcycle2 ndcycle3 rdcycle5758MRS monitoring of ChemotherapySilicone Implant Rupture MRI• MR is the definitive exam for implantassessment.• Non-contrast unless a question ofcancer.4 th cycle 5 th cycle 6 th cycleSiliconeCourtesy of FHDI and USCD5960Implant ruptureConclusion• MRI is the ‘gold standard’ if resources are available.• Combined approach with Mammogaphy and Ultrasound.• Should be used for screening high risk cases.• Should be used to assess all diagnosed breast cancer.• Use scoring system and BI-RADS• You will get false positives• No false negatives• Don’t screen unless you can biopsy.

61Thank you!Richard TuftFRCS, FRCR, FFRad(D)(SA)ISRRT Durban 2008