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ROLE OF MRI IN BREAST IMAGING

DEEPA MASRANI MDBREAST IMAGING AND INTERVENTIONAL RADIOLOGISTRadiology Assoc. of South Florida MIAMI,FL

Disclosures

I DO NOT HAVE RELEVANT COMMERCIAL RELATIONSHIPS

Resources

• American Journal of Roentgenology February 2017,Vol 208, Number 2

• Society of breast Imaging Resources

• Breast MRI: New and Abbreviated Protocols by Christopher Comstock MD

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Learning Objectives

• INDICATIONS OF BREAST MRI

• APPROACH TO BREAST MRI

• BREAST MRI INTERVENTION

• ROLE OF ABBREVIATED MRI PROTOCOL FOR SCREENING

Indications of Breast MRI

• As an adjunct to MG and US to improve detection and characterization of cancer.

• To evaluate extent of cancer

• Detecting multifocality , multicentricity of breast cancer.

• Treatment Response to chemotherapy

• Differentiating between scar tissue and recurrent cancer after BCT

Advantages of breast MRI

1.Not limited by breast density

2.No ionizing radiation

3.Most sensitive test for breast cancer screening

4.PPV similar to mammography

5.Preferentially detects higher grade lesions

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• Screening in high risk patients (life time risk of > 20%)

• Examining breasts with metastatic LN with primary of unknown origin

• Patient with known cancer in one breast and screening of contralateral breast for occult cancer.

• Breasts with Implants

• Sensitivity of MRI is as high as 90% in some studies.

• Specificity – 50 – 70 %..... Disadvantage

• High false positives

• NPV 88-96%

• Organized

• Consistent

Approach to Breast MRI

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• Clinical Indication

• History and Physical examination

• Prior films ( mammograms, ultrasound prior Breast MRIs)

• Consistent viewing protocol

Summary of Report:

• Clinical Indication

• Comparison studies

• MRI technique

• Findings: Morphology and Kinetic curves

• Overall Assessment (BIRADS) and Recommendations

Sequences

• T1, T2 non fat saturated

• T2 axial fat saturated

• T1 pre contrast fat saturated

• Post contrast – T1 fat sat 1,2,3,4,5,6 mins

• Subtraction images T1 fat sat

• Sagital post contrast

• Post processing - MIP

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Practical Approach

• What is the background enhancement?

-Minimal, mild, moderate, marked

• Is there a discrete lesion that stands out in that background?

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Causes of increased background enhancement

• Hormone replacement therapy

• Chemotherapeutic agents – Adriamycin

• Herbal hormones

• Thyroid hormones

• Cardiac effect

Causes of decreased background enhancement

• Tamoxifen

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Practical Approach

• What is the type of lesion?

- Focus < 5 mms.

- Mass > 5 mms.

- Non mass like enhancement

Lesion Characteristics

Mass

Shape: round , oval, lobular, irregular

Margins: Smooth , irregular , spiculated

Internal enhancement :HomogenousHeterogenousRim enhancementDark internal septationEnhancing internal septationsCentral enhancement

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Poorly differentiated ductal carcinoma with necrosis and signet ring cell features

Contrast-enhanced T1-weighted fat-saturated GRE image

T2-weighted fat-saturated image

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T2-weighted fat-saturated image shows a region of low signal intensity in the portion of the mass that appears enhanced

Palpable mass in a 28-year-old woman, 3 months postpartum Contrast-enhanced T1-weighted fat-saturated shows an irregular mass with an irregular and spiculated margin, features typical of invasive carcinoma

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Non Mass like enhancement( is an area that is not a mass)

- Focal area

- Linear: Enhancement in a line not conforming to a duct

- Ductal: Enhancement in a line that may have branching and conforming to a duct.

- Segmental

- Regional

- Diffuse

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Regional micronodular (<5 mm Stippled or punctate) enhancement in fibrocystic breast tissue

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Associated (other) findings

• Nipple retraction , Nipple invasion• Pre-contrast high ductal signal • Skin thickening , skin invasion• Edema• Lymphadenopathy• Pectoralis major/chest wall invasion• Hematoma , blood• Abnormal signal void• Cysts

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Kinetic Curve assessment

• Type 1 – Slow initial rise and persistent

• Type 2 – Medium initial rise and plateau

• Type 3 – Rapid initial rise and rapid washout

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Type I enhancement curve in a lesion stable over 2 years indicates progressive enhancement in the lesion. The patient, a 28-year-old woman,benign finding

Type 2 and 3 curve in a multifocal and bilateral invasive lobular carcinoma in a 39-year-old woman

Type 1,2,3 curves from multifocal infiltrating lobular carcinoma in a 40-year-old woman indicate early washout.

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BIRADS Assessment

• Category 0 – Incomplete , need additional imaging evaluation

• 1 – Negative

• 2 – Benign

• 3 – Probably Benign

• 4,5 – Suspicious, need Biopsy

• 6 – Known Malignancy

Enhancement patterns in DCIS

Enhancement patterns in

invasive ductal carcinoma

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Enhancement patterns in invasive lobular carcinoma

Mass with spiculated margins

Mass with rimlikeenhancement and associated segmental clumped enhancement.

Nonmass like regional moderate enhancement

Implant Rupture

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Implant – Extracapsular Rupture

Breast MRI Interventions

• MRI Guided breast biopsies

• MRI Guided Wire localizations prior to surgical excisions/lumpectomies

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Pre-operative MRI Guided Needle localizations

• Hawkins needles – 5, 7.5, 10 cms

• Kopans needles

ABBREVIATED BREAST MRI

• Breast MRI is not cost effective for screening women with intermediate risk including those with dense breast as only risk

• Abbreviated MRI protocols have been proposed as a way of achieving efficiency and rapid throughput

• Provide increased availability and greater access to breast MRI

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Advantages of AB-MR

1. Low Cost ($300-$500)2. Quick (less than 10 mins)3. PPV similar to MG (20-30%)4. 150% increase in cancer detection5. Optimal screening interval 1-3 yrs?6. Interpretation guidelines7. Reader Qualifications8. Quality Accreditations

Conclusion

• Breast MRI plays a significant role in screening for breast cancer

• Important role in management of breast Cancer

• Future of Abbreviated Breast MRI in screening for breast cancer