WHICH INDICATION FOR BREAST MRI - Belgian Menopause Society by ewghwehws

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									WHICH INDICATION FOR
    BREAST MRI?




        Dr. P. De Visschere, Prof. Dr. G. Villeirs
        Genitourinary Radiology and Mammography
        University Hospital Gent
        Symposium Belgian Menopause Society
        13/03/2010
    Which Indication For Breast MRI?

•   Breast MRI
•   Contra-Indications
•   No Indications
•   Indications
                   Breast MRI




Bilateral breast coil
Prone position
Contrast bolus injection (Gadolinium IV)
T Two Water White
                        Breast MRI

                                     T1




                                     T1 +
              T2                     Gd




                                     sub


        Cor T1 fs +Gd
   Breast MRI Lesion Evaluation


• Morphologic evaluation
    • Lesion size, contour, internal architecture, …


• Dynamic contrast enhancement evaluation
    • Time-intensity curves
       – multiple T1 fs GE runs (images every 80 sec) over 5-8
         min
      Morphologic evaluation
 Lesion size, contour, internal architecture
 Round/Oval, homogeneous, regular contour  benign




Heterogeneous segmental or spicular contour  malignant
Dynamic Contrast Enhancement Evaluation
                  Principles of enhancement

         Invasive lesion                   Enhancement
       Angiogenetic factors
  Growth of existing capillaries      Increased in- and efflux
     De novo angiogenesis           Increased extracellular space
   Abnormal configuration: AV-        Increased extravasation
 shunts and defective endothelium
                                                   180
                                                   160
                                                   140
                                                   120
                                                   100
                                                    80
                                                   60
                                                   40
                                                   20
                                                    0
                                                         1   2   3   4   5   6
Dynamic Contrast Enhancement Evaluation
                  Time-intensity curves
 Signal
 intensity

   120


   100


    80                                       Carcinoom
                                             Fibroadenoom
    60                                       Hyperplasie
                                             Normaal klierweefsel
                                             Spier
    40


    20


      0
          0   1   2      3     4      5   Time (minutes)
Dynamic criteria
Time-intensity curves


                     Type 1 curve
                Linear curve, continued
                     enhancement
                    Usually benign
Dynamic criteria
Time-intensity curves


                      Type 2 curve
                      Plateau curve
                    4-6’ = peak 1-3’
               (maximum variation of plateau in
                 delayed part of slope: 10%)

                 Benign and malignant
Dynamic criteria
Time-intensity curves


                    Type 3 curve
                   Wash-out curve
                  Usually malignant
      Accurracy Breast MRI
• Very high sensitivity (83-100%) in the
  detection of invasive breast cancer

• Modest specificity (29-100%)

• Very high negative predictive value
  (>98%) for invasive carcinoma
        Accurracy Breast MRI
              False Positives

• Angiogenetic activity is not exclusive for
  malignancy
• Lesion with high vascularisation: overlap
  between benign and malignant
     • E.g.: Fibroadenoma time-intensity curves:
           » 83% linear curve
           » 12% plateau curve
           » 5% wash-out curve
          Accurracy Breast MRI
                    False Positives
• MRI of dense breast: high background enhancement
  – Diffuse or focal enhancing zones, without mass-effect
  – Usually linear curve (type 1 curve), infrequently plateaucurve
• Histology: benign hyperplastic disease, adenosis,
  epitheliosis, …
• Endogeneous or exogeneous hormones cause (focal)
  hyperemia
   Premenopausal patient: image between day 5 and 12 of menstrual cycle
   Postmenopausal patient: discontinue substitution 6 weeks before MRI
                                        180
                                        160
                                        140
                                        120
                                        100
                                         80
                                         60
                                         40
                                         20
                                          0
                                              1   2    3      4      5   6
         Accurracy Breast MRI
                 False Negatives
• Lesion with poor enhancement pattern
  – Invasive malignancy very unlikely:
     • Well differentiated invasive breast cancer
     • Invasive lobular carcinoma
  – DCIS
     • In 16-40% false negative
     • Many cases of DCIS show slow initial enhancement and no
       washout
     Accurracy Breast MRI
             False Negatives
            Invasive Lobular Carcinoma

    Diffuse infiltration of surrounding tissue
            (‘Indian file’ configuration)
Nutrition via existing capillaries or cellular diffusion
       Accurracy Breast MRI
              False Negatives
                       DCIS

 Tumor inside duct or lobule (intact basal membrane)
          Nutrition via ductolobular system


DCIS
 BUBO: Breast Unidentified Bright Object

• Enhancement of a node <5mm
  – Too small to characterize
  – ‘normal background
    enhancement’
  – Usually stable on follow-up
    examinations
  – Risk of malignancy extremely
    low
Contra-indications
 (Breast)-MRI
Contra-Indication (Breast)-MRI:
        Ferromagnetic structures




Pacemaker, neurostimulator, hearing device,
dental prosthesis, metallic splinter in the eye, …
http://www.mrisafety.com/list_search.asp
  Contra-Indication (Breast)-MRI:
                Claustrophobia




Noise 60-90dB
20 minutes
Contra-Indication (Breast)-MRI:
        Chronic Renal Failure

• Severe Chronic Renal Failure
  – Gadolinium  nephrogenic systemic fibrosis
    • Glomerular filtration rate (GFR) <30 ml/min
    • Cockroft Gault GFR calculator:
      http://www.nephron.com/cgi-bin/CGSI.cgi
Contra-Indication (Breast)-MRI:
               Pregnancy

• First 3 months pregnancy: avoid MRI
 No Indication
for Breast-MRI
No Indication for Breast MRI:
      Microcalcifications
       • Microcalcifications on
         mammography
         – No enhancement on MRI:
            • False negative in DCIS (NPV <85%)
         – Enhancement on MRI
            • False positive in benign hyperplastic
              disease
       • MRI  Biopsy!
No Indication for Breast MRI:
   Screening low-risk patients


        • Screening low-risk patient with
          dense breasts
          – MRI  MX + US
No Indication for Breast MRI:
        Alternative for Biopsy

• Evaluation suspicious
  lesion on MX/US
  – MRI  Biopsy!
Indications
Breast-MRI
          Indications Breast-MRI
• Indications limited due to modest specificity
• When in doubt first discuss indication with the
  radiologist
   •   Screening high-risk patients
   •   Preoperative evaluation
   •   Detection recurrence after surgery
   •   Evaluation neo-adjuvant chemotherapy
   •   Evaluation breast implants
   •   Axillar adenopathy or metastasis with normal MX and US
   •   (discrepancy MX  US)
   Indications Breast MRI

Screening High Risk Patients
       Indications Breast-MRI:
       Screening High Risk Patients
• High risk patients
    <40y: MR/y
    >40y with dense breasts: MR/y
               (and MX+US/y)
• Advantages Breast-MRI:
  – Highest sensitivity
  – No radiation
        Indications Breast-MRI:
        Screening High Risk Patients
• EVA Trial, J of Oncology Report, 22 feb 2010
  (C. Kuhl):
  – In women at elevated familial risk (>20%), MRI
    screening shifts the distribution of screen-detected
    breast cancers to the preinvasive stage.
  – Neither annual MX nor annual/half-yearly US add
    to the cancer yield achieved by MRI alone.
Indications Breast MRI

Preoperative Evaluation
        Indications Breast-MRI:
            Preoperative Evaluation
• After diagnosis unifocal mammacarcinoma
  – Multifocality? Multicentricity?
  – Contralateral breast? (synchronous ca in 5-20%)
  – Chest wall involvement?
        Indications Breast-MRI:
          Preoperative Evaluation
• MRI highest accurracy for
  evaluation lesion size and extension

• MRI changes treatment in 10-20%
  – Tumorectomy to more extensive
    surgery or mastectomy
     Indications Breast-MRI:
        Preoperative Evaluation

• Modest specificity of MRI:
  – Only 20% of additional foci are malignant
• False positives  extra biopsy
  – Sometimes only possible with MR-
    guidance
  – Extra time, costs, patient anxiety, …
      Indications Breast-MRI:
          Preoperative Evaluation

• Importance of these synchronous
  detected lesions is still unclear:
  – Can they be treated successfully with radiotherapy
    or chemotherapy?
  – Without treatment will they evolve to life-
    threatening tumors?
       Indications Breast-MRI:
          Preoperative Evaluation

• Indications preoperative MRI controversial
  – MRI in every new diagnosis of mammacarcinoma?
  – MRI only in new diagnosis of mammacarcinoma in
    mammographic dense breasts?
  – No MRI staging?
        Indications Breast-MRI:
           Preoperative Evaluation

• COMICE-trial (L. Turnbull, The Lancet, february 2010)
   – 1600 patients, all MX, US and biopsy;
   – 800 in addition also preoperative MR
   – MR group in 16% more extensive surgery
   – No significance difference in reoperation rate
     after 6 months (18 % vs 19%) :
   – Conclusion preop MR not usefull
Indications Breast MRI
Detection Recurrence
   After Surgery
     Indications Breast-MRI:
 Detection Recurrence After Surgery

• Scar tissue or recurrence?
      wait (3) – 6 months after surgery
     wait (12)-18 months after radiation therapy
  • Enhancement 2 years after completion of
    treatment is suspicious
                       Scar tissue

 Recent scar (< 12-18m):        Old scar (> 18 m): fibrous
hypervascular inflammation       hypovascular tissue with
 with strong enhancement           few/no enhancement
 Indications Breast MRI

Evaluation Neo-adjuvant
    Chemotherapy
    Indications Breast-MRI:
Evaluation Neoadjuvant Chemotherapy


 • MRI highest accurracy for monitoring
   chemotherapy
 • Change in (residual) tumor size, signal
   intensity and contrast kinetics
 • Underestimation possible!
     Monitoring chemotherapy




• Underestimation possible!
  Indications Breast MRI

Evaluation Breast Implants
      Indications Breast-MRI:
        Evaluation Breast Implants

• Prosthesis complications
  – Rupture of the capsula, fibrosis, dislocation, …
  – Silicone implants:
     • MRI is first-line investigation
        – sensitivity MRI 80%, US 60%, MX 40%

• Detection of tumor recurrence
  – Interpretation MX and US difficult
                 Breast Implants




Prepectoral / Retropectoral
Linguine sign
    Indications Breast MRI

Axillar adenopathy or metastasis
   with normal MX and US
      Indications Breast-MRI:
  Axillar adenopathy or metastasis with
            normal MX or US


• MX, US and clinically no tumor detectable
• Detection of primary tumor
  < 2% of all breast cancers are found via metastatic
    axillar lymph nodes
• Sensitivity of MRI in these cases: 75-85%
  Indications Breast MRI

(Discrepancy MX  US)
         Indications Breast-MRI:
          (Discrepancy MX  US)


• Discrepancy clinical findings  MX  US
  – E.g. bloody nipple discharge, …
• First consider biopsy, retrospective evaluation, …
• MRI high sensitivity, modest specificity:
  –  False positives
Take home messages
    Take home messages…

• Accurracy Breast MRI for IDCA:
  – Very high sensitivity
  – Modest specificity
  – Very high negative predictive value
      Take home messages…

• Contra-indications for (Breast)-MRI
  – Ferromagnetic structures
  – Claustrophobia
  – Severe chronic renal failure
  – Pregnancy <3 months
       Take home messages…

• No Indications for Breast MRI
  – Microcalcifications
  – Screening low-risk patients
  – Replacement of biopsy
      Take home messages…

• Indications Breast-MRI
  – Screening high-risk patients
  – Preoperative evaluation
  – Detection recurrence after surgery
  – Evaluation neo-adjuvant chemotherapy
  – Evaluation breast implants
  – Axillar adenopathy or metastasis with normal
    MX and US
  – (Discrepancy MX  US)
       Take home messages…


• When in doubt first discuss indication with
  the radiologist
• Provide thorough clinical information and
  previous imaging studies (MR/MX/US)
Thank you for your attention!

                Pieter.DeVisschere@uzgent.be

								
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