diagnosis of breast lesions with mrimri/seminars/slides/diagnosis of breast lesions...10/4/10 1...

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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




  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




  Mammography

  Ultrasound


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




  Mammography

  Ultrasound


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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




  Mammography

  Ultrasound


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




  Mammography

  Ultrasound


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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?


Non-Mass Findings   Enhancement

  Distribution   Focal area

  Linear

  Ductal

  Segmental

  Regional

  Multiple regions

  Diffuse

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  Distribution

  Focal area

  Linear

  Ductal

  Segmental

  Regional


  Diffuse

  Pattern   Homogeneous or inheterogeneous

  Heterogeneous or inhomogeneous

  Stippled / Punctate

  Clumped / Cobblestone

  Reticular / Dendritic


  Distribution

  Focal area

  Linear

  Ductal

  Segmental

  Regional


  Diffuse

  Pattern

  Homogeneous or inheterogeneous

  Heterogeneous or inhomogeneous

  Stippled / Punctate

  Clumped / Cobblestone

  Reticular / Dendritic

  Symmetry / Asymmetry   Laterality

Non-mass Morphology?








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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?

diagnosis of breast lesions with mrimri/seminars/slides/diagnosis of breast lesions...10/4/10 1...

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