irm mammaire birads - sarimmalignant breast masses detected only by ultrasound, a retrospective...
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IRM Mammaire Birads
TH. DAO, Unité d’Imagerie Sénologique
Hôpital Henri Mondor
Créteil – France
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IRM DU SEIN : DIAGNOSTIC
• Mammographie ++
• Échographie
• IRM ?
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IRM DU SEIN : DIAGNOSTIC
Mammographie : 15% des cancers ne sont pas détectés:
• pb technique (amélioration avec le
dépistage et les contrôles techniques)
• radiologue (autre lésion détournant
l’attention: 44% )
• densité du sein (34% à 53% des cas)
Mammographic characteristics of 115 missed cancers later detected with screening mammography and the potential Utility of CAD. RL Birwell, DM Ikeda, KF O’Shaughnessy, EA Sickles Radiology 2001; 219:192-202
Analysis of cancers missed at screening mammography. RE Bird, TW Wallace, BC Yankaskas
Radiology 1992; 184:613-617
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Lésion du QSE Dt sans traduction mammographique
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• Echographie : 0,3% de cancers détectés supplémentaires, avec mammo et clinique normales
• Effectuée dans 30% des cas en moyenne (20-85%)
• Coût (non compris dans le dépistage)
• Opérateur dépendant
Malignant Breast Masses Detected Only by Ultrasound, A Retrospective Review
PB Gordon, SL Goldenberg
CANCER August 25,1995, Volume 76, No. 4, 626-630 .
IRM DU SEIN : DIAGNOSTIC
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IRM du sein:
Outil diagnostique important dans un bilan sénologique
Examen complémentaire des autres techniques d’imagerie
Nombreuses études d’évaluation depuis les annes 80: controverses et confusion
sémiologie et limites de l’examen maintenant connues
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Intérêt de l’IRM
Nombreuses études depuis 1985: l’IRM pour quel diagnostic ?
Nb Se (%) Sp (%) Etude
Heywang et coll 1988 32 99,5 28 Pré-op
Kaiser et coll 1989 82 97 97 Pb
Dao et coll * 1993 26 88 95 Post-RX
Gilles et coll 1993 26 93 63 Post-op
Harms et coll 1993 30 94 37 Pré-op
Heywang et coll 1994 76 100 78 doses
Hulka et coll 1995 20 86 93 Pré-op
* Tumor recurrence versus fibrosis in the irradiated breast: differenciation with dynamic gadolinium MR imaging. Dao TH, Rahmouni A, Campana F, Laurent M, Asselain B, Fourquet A, Radiology 1993 ; 187 : 751-756
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IRM du sein:
Grande sensibilité (92%)
Importante VPN (89-98%)
Faux positifs connus (jusqu’à 40% chez une
patiente non ménopausée, mastopathie bénigne,
cycles, THS, certaines histologies: CIS,
C.Lobulaires ...)
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BIRADS
• Groupe de travail initié par l’ACR (American College of Radiology) en 1999
• « Lexicon »: dictionnaire des termes à employer sur les IRM mammaires avec injection
• Nombreuses avancées technologiques: antennes, puissance de champ, séquences rapides, résolution temporelle et spatiale etc …
• Nouvelles données de réhaussement dynamique
MRI Birads 1st edition (2003)
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Définition des termes :
- densité du sein en terme de composition de glande
(graisseux, hétérogène …)
- « masse et non-masse »
- cinétique de réhaussement
- forme de réhaussement
- Corrélation avec la mammographie,
l ’échographie
- conduite à tenir, même après biopsies
MRI Birads 1st-5th edition (2003 -2012)
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MRI Birads
Recommandations techniques:
-Antenne de surface dédiée
-Séquence T2 ou T2 fat sat
-Injection de produit de contraste
-Séquence T2 avant injection
-Résolution temporelle et spatiale
-Diffusion et spectroscopie optionnelles
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T1
Post Gadolinium
1’
2’
3’
4’
5’
6’
Tumeurs malignes en IRM
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Voir ce réhaussement:
TUMEURS MALIGNES EN IRM
intérêt de la soustraction
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Tumeurs malignes en IRM : intérêt de la soustraction
Post Gadolinium
1’ 1’
2’
3’
4’
6’
6’
?
Après injection de Gd et soustraction: 2 lésions
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Tumeurs malignes en IRM : voir le réhaussement:
séquences en excitation d’eau (et saturation de graisse)
?
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Tumeurs malignes en IRM
Aspect IRM d ’une tumeur maligne après Gadolinium (spécificité +++) :
• réhaussement intense, hétérogène, focal,
• réhaussement irrégulier, canalaire, voire annulaire,
• « wash-in » précoce avec pente raide,
• « wash-out »
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• Différentes courbes de réhaussement
de tumeurs malignes :
- wash-out III: 57%
- plateau II: 33%
- progressive Iab: 9%
(d’après K.Kuhl et al,
Radiology 1999 ; 211 :101-110)
TUMEURS MALIGNES EN IRM
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TUMEURS MALIGNES EN IRM
• Injection de Gadolinium, dynamique: réhaussement de signal selon des courbes
(wash-out) (57%) (plateau) (33%) (curviligne) (9%)
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IRM du sein
Types de courbes de réhaussement des tumeurs malignes, lésions bénignes
solides et dysplasie fibro-kystique (N/PFC)
(d’après K.Kuhl et al, Radiology 1999 ; 211 :101-110)
type I: curviligne
type II: plateau
type III: wash-out
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IRM Mammaire avec injection dynamique de
Gadolinium:
Se = 90-95% mais Sp = 40-50 % *
Tumeurs malignes en IRM
IRM Mammaire doit combiner les séquences dynamiques et les séquences morphologiques T1, T2
* Hewyang et al. 1988; Harms et al. 1994
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IRM Birads
Séquence T2: T2 fat sat:
-Hypersignal T2
> parenchyme
> vaisseaux
> eau, graisse
- à réaliser AVANT injection Gd
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IRM Birads
Lésions bénignes hyper T2:
-Kyste ou composante kystique
-Graisse altérée
-Fibroadénome « jeune »
-Ganglion intra-mammaire
-T phyllode
Lésions malignes hyper T2: -Tumeur nécrosée (CT)
-Mucineux
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CCI et Mucineux en hypersignal T2
T2 STIR
T1 Gadolinium
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IRM Birads
Morphologie des lésions:
-Masse: - lésion avec effet de masse > 5mm,
- - avec des limites nettes
- - réhaussemnt interne
- - des caractéristiques T1, T2 et après Gd
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IRM Birads
Morphologie des lésions:
-Masse: Contours (résolution spatiale ++)
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IRM Birads
Morphologie des lésions:
-Masse: Contours
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IRM Birads
Morphologie des lésions:
-Masse: Réhaussement interne
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IRM Birads
Morphologie des lésions:
-Masse: Réhaussement interne
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IRM Birads
Morphologie des lésions:
Masse: Réhaussement périphérique
- cytostéatonécrose
- kyste inflammatoire
- tumeur triple négative
(RO, RE, Herceptin)
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IRM Birads
Morphologie des lésions:
Non-masses:
- réhaussement différent d’une masse, d’un
vaisseau
- pas d’effet de masse
- pas de traduction T1, T2
American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. Saslow D, Boetes C, Burke W, et al. CA Cancer J Clin. 2007;57:75-89.
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IRM Birads
Morphologie des lésions:
Non-masses :
-Focal
-Linéaire (plutôt que ductal)
-Branchée
-Segmentaire
-Régionale
-Multiple
-Diffuse
-Symétrique ou non
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IRM Birads
Morphologie des lésions:
Non-masses :
- Carcinome in situ ++
- K RE-
- Carcinome lobulaire in situ
- mastose fibrokystique
- inflammation
- THS
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Carcinome in situ
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• Récidives plus fréquentes quand l’exérèse est
incomplète, berges atteintes
• 46 % récidivent sous forme invasive
• 20% avec des métastases à 10 ans
• Nécessité d’un bilan d’extension précis ++
Risk factors for recurrence and metastasis after breast- conserving therapy for ductal
carcinoma-in-situ: analysis of European Organization for Research and Treatment of
Cancer
Bijker N, Peterse JL, Duchateau L, et alTrial 10853.
J Clin Oncol 2001;19(8):2263–2271.
Carcinomes in situ
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• Place de l’IRM ?
• Pas de signal IRM des microcalcifications ++
• Prise de contraste dans +/- 70% des cas
• (faux négatif dans ± 30% cas …)
Carcinomes in situ
MRI for diagnosis of pure ductal in situ: a prospective observational study. Kuhl CK, Schrading S, Bieling HB, et al. Lancet 2007; 370(9586):485-92
Pure ductal carcinoma in situ: a range of MRI features
S.Raza, M.Vallejo, SA.Chikarmane, RL. Birdwell. AJR 2008; 191:689-699
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• Hypo ou iso-intense en T1
• Iso ou hyperintense en T2
IRM DU SEIN
Réhaussement après injection: -non-masse: 59% -Masse: 14%
-Pas de réhaussement: 14%
-Focus: 12%
Répartition du réhaussement :
-Segmentaire: 42% -Focal: 33%
-Linéaire: 9% -Diffus: 9%
-Régional: 6%
Réhaussement interne: -Multinodulaire: 51% -Hétérogène: 21%
-Homogène: 15% Radiologic-Pathologic Correlation of Ductal Carcinoma in Situ Takayuki Yamada, Naoko Mori, Mika Watanabe, Izo Kimijima,
Tadayuki Okumoto, Kazumasa Seiji, and Shoki Takahashi
Radiographics September 2010 30:5 1183-1198
Carcinomes in situ
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Carcinome in situ grade II-III Van Nuys:
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Patiente de 67 ans,
antécédents familiaux
(tante maternelle)
Apparition de microcalcifications du
sein droit
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• CIC étendu à l’anapath
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IRM Birads
Morphologie des lésions:
-Focus, foci <5mm :
- Réhaussement punctiforme non-masse
- arrondi
- de contours flous
- de même taille si plusieurs
- bénin
- « mastose »
- parenchyme normal
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IRM Birads
-Focus, foci <5mm :
- prises de contraste observées dans près de 80%
des cas avant ménopause
- prises de contraste maximales à la 1ère et 4ème
semaine du cycle
IRM à la 2ème semaine du cycle
Healthy premenopausal breast parenchyma in dynamic contrast-enhanced MR imaging of the
breast: normal contrast medium enhancement and cyclical-phase dependency.
Kuhl CK, Bieling HB, Gieseke J, Kreft BP, Sommer T, Lutterbey G, Schild HH.
Radiology. 1997 Apr;203(1):137-44.
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• Phase folliculaire proliférative
(oestrogènes, prolifération
vasculaire/perméabilité
2ème partie de cycle
1ère partie de cycle
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Mastopathie bénigne
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Nodule de « mastose »
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IRM Birads
Réhaussement matriciel (Background parenchyma,
BPE):
-1ère soustraction
-Réhaussement matriciel qui peut gêner pour
l’interprétation et la détection des prises de
contraste
-Modifié par cycles hormonaux, RT, Tamoxifène
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MRI Birads
Minime (0-25%) Modéré: 25-50%
Dense +/- hétérogène: 50-75% Très dense: > 75%
Aspect sur le 1er temps soustrait après injection:
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Réhaussement mammaire et classification ACR-IRM
Réhaussement important
ACR 3 plus fréquent …
DeMartini, AJR 2012
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IRM Birads
Réhaussement matriciel (Background parenchyma,
BPE):
-Prises de contraste moins intenses, symétriques
-Foci
-Segmentaires
-Postérieures en « cadre »
-Courbes de réhaussement monophasiques
-Pas de wash out
-Pas de corrélation avec la densité Birads du sein
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IRM du sein: Réhaussement du parenchyme normal (Background Parenchyma Enhancement: BPE)
Pas de corrélation entre la densité Birads du sein en mammo et le
réhaussement du parenchyme en IRM
BPE 1 minime BPE 2
modéré
BPE 3 dense
hétérogène
BPE 4 très dense
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IRM du sein: Réhaussement du parenchyme normal (Background Parenchyma Enhancement: BPE)
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IRM du sein: Réhaussement du parenchyme normal (Background Parenchyma Enhancement: BPE)
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IRM du sein: Réhaussement du parenchyme normal (Background Parenchyma Enhancement: BPE)
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IRM du sein: Réhaussement du parenchyme normal (Background Parenchyma Enhancement: BPE)
Réhaussement punctiforme Réhaussement régional
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IRM du sein: Réhaussement du parenchyme normal (Background Parenchyma Enhancement: BPE)
MINIMU
M
61%
MARKED
54%
MINIMUM
61%
Post-menopausal women Pre-menopausal women
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IRM Birads
Prothèses :
-Rétro-glandulaire ou rétro-pectorale -Contenu (silicone, saline)
-Rupture intra ou extra-capsulaire
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TSE T1
T2 STIR
Saturation Silicone
Visualisation Silicone
Protocole Mondor: -Séquences de saturation de silicone - Visualisation du silicone (water and fat saturation)
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Visualisation Silicone Saturation Silicone
T2 STIR TSE T1
Microfissures prothèse gauche
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TSE T1 T2 STIR
Saturation Silicone Visualisation Silicone
Rupture complète sous-capsulaire prothèse sérum physiologique
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Nodule sous-prothétique à l’échographie
STIR Gadolinium
Granulome réactionnel (« siliconome »)
À une « hernie » de la prothèse
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Saturation Silicone T2 STIR
Antécédents de cancer du sein droit traité par
mammectomie-prothèse, mammectomie gauche
prophylactique, prothèse.
Rétraction mammaire droite
: carcinome canalaire
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IRM Birads Compte-rendu
Compte-rendu
-Intégrer les autres imageries (mammo, écho)
-Clinique
-Signes IRM (morphologie, réhaussement ….)
- Classification Birads globale - ACR 0 - ACR 1 ou ACR 2 - ACR 3 : surveillance IRM - ACR 4 : échosecond look, +/- biopsie - ACR 5 : « ou biopsie sous IRM
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Prise en charge « optimale » d’une lésion classée mammo-écho ACR 4-5
Lésion ACR4-5 M/E
Biopsie guidée M/E
Bilan d’extension IRM (seins denses, femme jeune, à risque,
lobulaire …)
STOP
Lésion additionnelle (3-25%)
Echographie de « second look »
Nouvelle biopsie écho-guidée Biopsie sous IRM
ou « surveillance »
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BIOPSIES SOUS IRM
Antenne à biopsie mammaire
Système de repérage
pour biopsie mammaire
Consommables compatibles IRM
(aiguilles, harpon, clip)
Temps-machine: 2 h/procédure en moyenne
Coût +++
Sites dédiés
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IRM Birads Conclusions
-Séquence T2
-Réhaussement matriciel
-Masses/non-masses (simplification)
-Prothèses mammaires
-Classification ACR IRM
-Classification ACR globale
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MERCI