Breast MRI of Invasive Cancer

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1 Breast MRI of Invasive Cancer BC Surgery Oncology Breast Cancer Update Audrey Spielmann,, MD

2 Outline Technique Indications Cases Pre-op Breast MRI Conclusion

3 Excluded Screening Post-op op MRI DCIS Breast Implant integrity Outline

4 Technique Breast MRI Questionnaire Name: Date of of Birth: Referring Physician: Reason for for Exam: Implant Assessment Enlarged lymph glands under arm arm Breast Lump (( right right // left left )) Known breast cancer (( R // L) L) Nipple Discharge (( right right // left left )) Other: Previous Mammogram Where/When: Previous Ultrasound: Where/When:

5 Technique Breast MRI Questionnaire Previous Breast Surgery: (( yes yes // no no )) Where/When: R/ L breast Benign // Malignant Pre-menopausal (( yes yes // no no )) First First day day of of LMP: Exam Exam should should be be scheduled for for Day Day of of cycle cycle Post-menopausal (( yes yes // no no )) On On HRT? HRT HRT should should be be stopped 3 months prior prior to to exam consult your your physician Do Do you you have a family history of of breast cancer (if (if yes, yes, please indicate age age of of diagnosis) Mother Sister Grandmother Aunt Aunt Daughter

6 Technique Breast MRI Questionnaire Have you you had had any any of of the the following treatments (If (If yes, yes, please indicate where & when) Lumpectomy Mastectomy Chemotherapy Radiation Tamoxifen HRT HRT // BCP BCP Needle biopsy Patient Signature: Date:

7 Technique Breast Coil

8 Technique Positioning

9 Technique Sequences Coronal STIR Ax FSE T2 or STIR 3D VIBRANT with fat saturation- precontrast,, immediate post injection and 3 more consecutive runs(scan time <1.5 minutes) Post-processing-subtraction subtraction

10 Breast MRI BI-RADS Lexicon Lesion Morphology Mass (3D) Area of non-mass-like enhancement Focus (<5mm) Enhancement Kinetics

11 MRI BI-RADS Lexicon Mass-Irregular shape

12 MRI BI-RADS Lexicon Mass-Irregular shape yo yo Mammo +, +, US US Bx Bx

13 MRI BI-RADS Lexicon Asymmetric Enhancement yo yo Bx BxDCIS

14 Breast MRI Enhancement Kinetics angiogenesis

15 Breast MRI Time-signal intensity curve 94% Benign 64% Malignant 87% Malignant Kuhl KuhlCK CK et et al. al. Radiology 2000;215:

16 Breast MRI Time-signal intensity curve Kuhl KuhlCK CK et et al. al. Radiology 2000;215:

17 Indications ACR practice guidelines (2008) Screening High risk patients Contralateral breast (3-5% occult malignancy) Breast Augmentation

18 Indications Breast Augmentation y woman woman Implants Implants y ago ago Palpable Palpable mass mass L Mammo Mammo + US US bx bx

19 Indications ACR practice guidelines (2008) Extent of disease Multifocality and Multicentricity Invasion deep to fascia Postlumpectomy + margins Neoadjuvant chemotherapy

20 Indications ACR practice guidelines (2008) Additional evaluation of clinical/imaging findings Recurrence Occult Breast Cancer Lesion characterization PO tissue reconstruction MRI-guided biopsy

21 Breast MRI Indications Pre-operative Evaluation Tumour size and location Multifocality & Multicentricity (occult disease 15-37%) Chest wall or pectoralis muscle invasion, nipple or skin invasion Axillary or internal mammary LN Metastasis

22 Breast MRI Indications Pre-operative Evaluation Ipsilateral cancer was found on MRI in 19/70 ((27%) 20% same quadrant 4% different quadrant 3% same and different Strong family Hx or infiltrating lobular histology Liberman L et et al. al. AJR AJR 2003; 2003; 180:

23 Breast MRI Indications Pre-operative Evaluation Liberman L et et al. al. AJR AJR 2003; 2003; 180:

24 Breast MRI Indications Pre-operative Evaluation Liberman L et et al. al. AJR AJR 2003; 2003; 180:

25 Breast MRI Indications Pre-operative Evaluation 50 yo woman 77 yo mother dx metastatic breast Ca Thickening L UOQ Mammo -,, US - in area but lesion in L UIQ US Bx infiltrating lobular Ca

26 Breast MRI Indications Pre-operative Evaluation

27 Breast MRI Indications Pre-operative Evaluation Lobular Carcinoma

28 Breast MRI Indications Pre-operative Evaluation y woman woman Palpable Palpable L breast breast mass mass

29 Breast MRI Indications Pre-operative Evaluation

30 Breast MRI Indications Pre-operative Evaluation

31 41 41 y woman woman Palpable Palpable L breast breast mass mass UOQ UOQ Bx Bxinfiltrating poorly-differentiated ductal ductalcarcinoma carcinoma Pre-op Breast MRI Chest Wall invasion

32 Breast MRI Indications Contralateral breast screening pre-op 3-5% synchronous contralateral breast Ca on MRI only 30/969 (3%) contralat breast Ca 121/969 (12.5%) Bx 30 + bx(24.8%) 18 invasive Ca 12 DCIS All node negative Lehman Lehman C et et al al N Engl EnglJ J Med Med 2007; 2007; 356: :1295

33 Breast MRI Indications Contralateral breast screening pre-op Risk of occult Ca in contralateral breast 1 year post neg MRI 0.3% Lehman Lehman C et et al al N Engl EnglJ J Med Med 2007; 2007; 356: :1295

34 Pre-op Breast MRI Radiological Perspective Additional breast tumour foci 15-37% ipsilateral breast 3-5% contralateral breast Alters clinical management 10-31% Biopsy of suspicious lesions before surgical approach

35 Pre-op Breast MRI Surgical Perspective Conflicting endorsement Cleveland clinic-fully promotes pre- op breast MRI without restriction 327 patients-25% pts occult but suspicious lesions 13% pts occult and separate tumours 75% no additional suspicious foci J Crowe, The Breast Journal, Vol 15 # 1, 2009, p52-60

36 Pre-op Breast MRI Surgical Perspective 267 patients invasive Ca Surgical management to wider/separate excision or mastectomy in 26% (69/267) Confirmed on path that necessary 71% (49/267) 46% lobular Ca altered management Bedrosian I et al, Cancer 2003, Vol 98,

37 Pre-op Breast MRI Surgical Perspective Occult primary malignancy BRCA1/2/other genetic mutation Major discrepancy between mammo and US (ILC, very dense breasts) M Morrow, Nature Clin Practice Oncology Feb2009 Vol 6 No2

38 Pre-op Breast MRI Assumptions Meta-analysis analysis observational studies (2610 women) Improved surgical planning Reduce re-excision excision surgery Reduce local recurrence Not substantiated by trials Additional foci tx with radiation & chemotherapy Houssami N & Hayes Hayes D, D, CA CA Cancer J Clin Clin2009

39 Pre-op Breast MRI Assumptions 15/18 studies quoted in the meta- analysis 2004 back to /18 > 2004 Marked improvement in image quality Houssami N & Hayes Hayes D, D, CA CA Cancer J Clin Clin2009

40 Increased risk of recurrence Involvement of surgical margins Extensive cancer ID clinically or mammographically Presence of locally advanced Ca Houssami N & Hayes Hayes D, D, CA CA Cancer J Clin Clin2009

41 Breast MRI Indications Pre-operative Evaluation Extent of cancer underestimated clinically and mammographically Liberman L et et al. al. AJR AJR 2003; 2003; 180:

42 Pre-op Breast MRI Pros Extent (MF vs vsmc) Screen CL breast Chest wall invasion Patient & Surgeon reassured Cons Additional Imaging Further biopsy Delay in in surgery More pt pt anxiety More extensive lumpectomy or or conversion to to mastectomy

43 Pre-op Breast MRI Conclusion Pre-op Breast MRI will find otherwise occult ipsilateral and contralateral tumour foci Must bx MRI suspicous lesions Patient awareness that further bx and delay in surgery Negative MRI for MC/CL disease reassuring

44 Pre-op Breast MRI Conclusion Particularly helpful Axillary nodes-occult occult primary Genetic Ca Lobular Carcinoma Very dense breasts/young patients

45 Pre-op Breast MRI Conclusion More research (randomized, controlled prospective trials) needed to study longterm impact on local recurrence, morbidity and mortality

46 Thank You!

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