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                                                 BREAST MRI
Breast MRI                                       BI-RADS
Richard Tuft                                     Indications
FRCS, FRCR, FFRad(D)(SA)                         Biopsy
ISRRT Durban 2008

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Equipment                                        Sequences and Technique

  1.5T Minimum                                    Fat saturation
  3.0T Ideal                                      Pre contrast STIR (T2 Fat Sat)
  Detachable tables                               Pre and post contrast FLASH3D (T1 Fat Sat)
                                                  Temporal and spatial sequences
                                                  Morphology and Kinetics
                                                  Scoring (BI-RADS)
                                                  Chest and upper abdomen staging studies
                                                  Prosthesis analysis

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When to scan                                     Sequences

  Pre-menopausal day 10-15                        Chest and Liver STIR
  6 Months after surgery                          Breast STIR
  12 months after radiotherapy                    Precontrast 3DFLASH
  Consider discontinuing HRT for 4-6 weeks        Postcontrast 3D FLASH with timed measurement of
                                                  Contrast uptake
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 FAT SATURATION                                         Pre-Contrast STIR with Fat Sat

   The key                                                    Axillae
   Fat sat failure                                            Chest wall
   Patient weight                                             Cysts
   T2 Without Fat Sat

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 FLASH 3D                                               High-spatial Resolution: delayed "VIEWS"

                                                          After dynamic exam.
   Pre and Post
                                                         Increased Resolution
   Contrast                                              Thin planes

                                                                                                   Courtesy of FHDI

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 Multi-modality Approach: The Key                       MR / Mammo Correlation:      Oblique MIP / MLO

                        High-resolution Compound US

Mammography                                           Courtesy: Dr. Bruce Porter
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Sagittal display:                                                                              Sagittal display:

 Multiplanar reconstruction from
     Dynamic VIEWS
     Delayed VIEWS
 Sagittal bilateral acquisition

                                                      SAG delayed VIEWS

                                  reconstruction of
                                  90 second
                                  Dynamic VIEWS

                    Courtesy of FHDI

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Kinetics                                                                                       3D fat-saturation dynamic VIEWS
                                            Tumour angiogenesis
                                            promotes a rich high density
                                            network of tumor vessels.                  1 min
                                            > 3mm, malignant infiltration,
                                            and metastatic disease.
                                            Enhancement quantification
                                            (dynamic MR) allows detection                            2 min
                                                                               Inline dynamic MIP
                                            of tumors to ~ 3 mm.,
                                            regardless of their
                                            morphology…                                                                3 min
                                                                                           1 minute subtraction

                                                                                                                                                                                           Courtesy of CSMC

                                                                                                                                           4 min

                                                                                                                                                              5 min

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Subtraction                                                                                    Kinetics

 Find enhancing area
 Apply ROI
 Assess Kinetics

                                                                                                                                                  I--------------- VIBE ---------------I
                                                                                                                  I---------- 3-D Dynamic --------I
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Enhancing Breast Cancer                         Features of Breast Malignancy:


                                              Courtesy: Dr. Bruce Porter

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BI-RADS                                         Grading                    BI-RADS®

 Published by ACR    0 - Incomplete exam               1          Normal Benign
 Mammography                                           2          Benign
                     1 - Normal
                                                       3          Probably Benign    Imaging follow up or tissue
 Ultrasound          2 - Benign                        4          Probably Malignant TISSUE
 MRI                 3 - Probably Benign               5          Malignant          TISSUE
                     4 – Probably Malignant
                     5 – Malignant
                     6 – Biopsy Proven

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BI-RADS MRI Scoring                             MRI Scoring System (Gottingen score)

                                                    Points                   0               1                2
 MRI Artefact Category    1-4                       Shape                                                     -
 Density Type             1-4                       Margins                  Well -defined   Poorly defined
                                                    Contrast                 Homogenous      Inhomogeneous    Ring
                                                    Initial Inc              <50%            50-100%          >100%
                                                    Post Initial             Increase        Plateau          Washout
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 MRI BI-RADS                                                    Enhancing Breast Cancer

     0 Points                              MRI BI-RADS 1
     1-2 Points                            MRI BI-RADS 2
     3 Points                              MRI BI-RADS 3
     4-5 Points                            MRI BI-RADS 4
     6-8 Points                            MRI BI-RADS 5

                                                                 7 Points = BI-RADS 5

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Breast Cancer                                                   Breast MRI
                                                                 Assessment and staging of breast cancer

1 in 8 women will be diagnosed with breast cancer
 Assuming a woman lives to the age of 85

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 MRI Breast Screening                                           MRI Breast Screening

     NEJM July 2004                                               52 Tumours
     1909 high risk women                                           44 Invasive carcinomas
     Risk > 15%, genetic or familial                                6 DCIS
     358 BRCA1 or BRCA2 positive                                    1 Lymphoma
                                                                    1 LCIS
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MRI Breast Screening                                           MRI Breast Screening

  Sensitivity                                                    Specificity
     Clinical          17.9                                         Clinical           98.1
     Mammography       33.3                                         Mammography        95.0
     MRI               79.5                                         MRI                79.5

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American Cancer Society Guidelines for                         Non-Screening Clinical Indications for Contrast
Breast Screening with MRI as an Adjunct                        Breast MR
to Mammography                                                   Lobular Cancer
                                                                 Occult Breast Cancer
 March 2007                                                      Close or positive surgical margins
 Screening MRI is recommended:                                   Post-operative scar vs. tumor recurrence
 for women with an approximately 20–25% or greater lifetime      Neo-adjuvant chemotherapy or brachytherapy
 risk of breast cancer,                                          Suspected multiple or bilateral cancers
 including women with a strong family history of breast or       Implants and known or suspected cancer
 ovarian cancer and                                              Problematic Mammogram
 women who were treated for Hodgkin disease.                     Assessment of all diagnosed breast cancers.

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MRI in unilateral breast cancer                                MRI in diagnosed breast cancer

 NEMJ March 2007                                                 April 2008
 969 with diagnosis of unilateral breast cancer                  European Breast Cancer Conference in Germany
 Other breast normal clinically and mammo                        249 patients who had malignancy on biopsy had MRI
 Occult cancer in second breast 3.1%                             Altered management in 13%
                                                                 20 additional cancers – 8%
                                                                 Better than mammo or US in assessing tumour size
                                                                 “We would like to see MRI become a standard preoperative
                                                                 treatment for breast cancer, along with biopsy,
                                                                 mammography, and ultrasound”
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  Unilateral vs. Bilateral        Multiple lesions
                                                   Infiltrating ductal Ca

     Cancers are
     bilateral in up to

     Exclusion of
     contra-lateral tumor
     is of great clinical
     and personal value

Courtesy: Dr. Bruce Porter
                                               Courtesy of FHDI

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Pathology with prostheses        Prostheses with pathology

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Extent of Tumour                 Lobular carcinoma larger than Mammo or

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Incomplete Excision              Neo-adjuvant Chemotherapy: Monitoring

                                              Courtesy of FHDI
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Contrast-enhanced Breast MR: Accuracy                                        Staging

 Varies significantly with technique and experience.
       Sensitivity:                      > 94 – 98 %
       Negative Predictive Value:        > 95 %
       Specificity:                      37 – 97 %
       Positive Predictive Value:        ~ 65- 75 %
 For DCIS sensitivity is lower, especially for low or
 intermediate grades; also for some lobular, low grade, or
 less angiogenic invasive carcinomas.

                                           Courtesy: Dr. Bruce Porter

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Chest STIR: Aids in cancer staging                                           MR - guided breast biopsies

  Look for highest positive lymph node
                                                                              Some lesions are not visible with mammography or
  Use body coil, supine placement                                             ultrasound (US)
                                                                              After identified with MR (diagnosis)
                                                                                 Many lesions can be found using US
                                                                                 US is interactive, cheaper, faster
                                                                                 MR-guided BB needed for those lesions which cannot be seen
                                                                                 in retrospect on US or mammaography

                  Courtesy of FHDI

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MRI Breast Biopsy Device                                                     Breast Biopsy

 Lateral and medial access
 Needle or wire placement
 (core, fna)
 Vacuum assisted biopsy
 Software controlled
 Comfortable patient
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 Spectroscopy - MRS                                       MRS monitoring of Chemotherapy

  Early results show specificity
  > 95%                                                  Before
  Choline peak at 3.6 ppm                                Chemo-                                                    1st
  Single voxel studies                                                                                             cycle

                                                         2nd                                                       3rd
                                                         cycle                                                     cycle

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MRS monitoring of Chemotherapy                             Silicone Implant Rupture MRI

                                                                                MR is the definitive exam for implant
                                                                                Non-contrast unless a question of

     4th cycle              5th cycle   6th cycle                                          Silicone

                                                                              Courtesy of FHDI and USCD

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 Implant rupture                                           Conclusion

                                                              MRI is the ‘gold standard’ if resources are available.
                                                              Combined approach with Mammogaphy and Ultrasound.
                                                              Should be used for screening high risk cases.
                                                              Should be used to assess all diagnosed breast cancer.
                                                              Use scoring system and BI-RADS
                                                              You will get false positives
                                                              No false negatives
                                                              Don’t screen unless you can biopsy.

Thank you!
Richard Tuft
ISRRT Durban 2008

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