Diagnosis of Breast Lesions with MRI

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1 Diagnosis of Breast Lesions with MRI George Trilikis, M.D. October 2, 2010 Breast MRI Indications Overview 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 Indications Guiding principles Alternatives Controversies The best test depends on what clinical problem one is trying to solve. Clinical Problem #1 Screening bmri Does my ASYMPTOMATIC patient have breast cancer? Principle #1: Earlier detection reduces the risk of dying of breast cancer. Screening. Principle #2: Any test is more accurate when the disease is more common. Therefore, higher risk groups are favored populations for screening. 1

2 High Risk Indications Probability of Breast Cancer and Ovarian Cancer during a 10-Year Period 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: ACS Recommendations Screening bmri Alternatives & Controversies: Do nothing Self breast exam Clinical breast exam Mammography Ultrasound Clinical Problem #2 Symptomatic bmri Does my SYMPTOMATIC patient have breast cancer? Lump Skin changes like dimpling, redness, thickening Nipple discharge Bloody Clear Serous Pain 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. 2

3 Clinical Problem #3 Staging bmri 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. 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 Clinical Problem #4 Alternatives & Controversies: Do nothing Self breast exam Clinical breast exam Mammography Ultrasound Surgical consultation 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 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. Alternatives & Controversies: Do nothing Self breast exam Clinical breast exam Mammography Ultrasound Surgical consultation 3

4 Clinical Problem #5 Response to Therapy bmri My patient is getting neoadjuvant chemotherapy. Is the tumor is responding? Principle #1: In theory, if the chemo isn t working, you could stop it or change to something different. Response to therapy. Pre / Post Example Response to Therapy bmri Alternatives & Controversies: Do nothing Self breast exam Clinical breast exam Mammography Ultrasound Surgical consultation Demonstrates importance of clip MRI can give us functional information by showing a decrease in the degree of enhancement before a decrease in size. Clinical Problem #6 Recurrence Does my patient have recurrent breast cancer? Similar to SCREENING and SYMPTOMATIC bmri. Alternatives & Controversies: Do nothing Self breast exam Clinical breast exam Mammography Ultrasound Surgical consultation 4

5 Clinical Problem #7 Silicone implant rupture Are my patient s SILICONE breast implants intact or ruptured? 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); ISBN: Accessed 10/2/10 Sagittal T2-weighted short-t1 inversionrecovery MR image (3,000/60 [repetition time msec/echo time msec]) obtained with fat suppression 45-year-old woman with extracapsular rupture of 15-yearold subpectoral single-lumen silicone gel implant shows intracapsular rupture of a silicone breast implant, as demonstrated by the linguine sign (arrow). Safvi A Radiology 2000;216: Berg, W. A. et al. Am. J. Roentgenol. 2002;178: by Radiological Society of North America Copyright 2007 by the American Roentgen Ray Society Summary of Indications Most Accepted High Risk Screening Occult Primary Silicone Implant Evaluation Questions? Less Widespread Agreement Staging Response to Therapy Recurrence Evaluation Symptomatic Workup 5

6 Keys to High Quality (HQ) bmri HQ: Sequences & Resolution Technologist Sequences and Resolution Appropriate clinical history and timing Patient positioning, comfort and cooperation 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 pre post T1 fat sat MIP sub 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 6

7 HQ: Clinical History & Timing HQ: Technologist 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 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 When & Where was prior imaging done? Outside films Local films HQ: Technologist HQ: Patient Factors How can I help speed and accuracy of interpretation? Document/Clarify Clinical History Positioning Comfort Cooperation Ask about previous imaging and get signed release form HQ: Positioning Make sure the coil is adequately open 7

8 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 Morphology Focus/Foci Mass Non-Mass-Like Enhancement Internal Enhancement Patterns Mass = 3D, space occupying lesion Shape Round Oval Lobulated Irregular Associated Findings Lesion Location Kinetic Curve Assessment 8

9 Morphology Morphology Mass = 3D, space occupying lesion Shape Mass = 3D, space occupying lesion Shape Round Oval Lobulated Irregular Margin Smooth Irregular Spiculated Margin Round Oval Lobulated Irregular Smooth Irregular Spiculated Internal Enhancement Characteristics Non Homogeneous Heterogeneous Rim Dark internal septations Enhancing internal septations Central Enhancement Morphology? Enhancement Distribution Focal area Linear Ductal Segmental Regional Non-Mass Findings Multiple regions Diffuse 9

10 Non-Mass Findings Non-Mass Findings Enhancement Enhancement Distribution Distribution Focal area Focal area Linear Linear Ductal Ductal Segmental Segmental Regional Regional Multiple regions Multiple regions Diffuse Diffuse Pattern Homogeneous or inheterogeneous Heterogeneous or inhomogeneous Stippled / Punctate Clumped / Cobblestone Reticular / Dendritic Pattern Homogeneous or inheterogeneous Heterogeneous or inhomogeneous Stippled / Punctate Clumped / Cobblestone Reticular / Dendritic Symmetry / Asymmetry Laterality 10

11 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. Nunes LW, Schnall MD, Orel SG, et. al. RadioGraphics 1999; 19: Plan ahead MR Guided Biopsies 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? 11

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