WHICH INDICATION FOR BREAST MRI?

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1 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

2 Which Indication For Breast MRI? Breast MRI Contra-Indications No Indications Indications

3 Breast MRI Bilateral breast coil Prone position Contrast bolus injection (Gadolinium IV)

4 T Two Water White Breast MRI T1 T2 T1 + Gd sub Cor T1 fs +Gd

5 Breast MRI Lesion Evaluation Morphologic evaluation Lesion size, contour, internal architecture, Dynamic contrast enhancement evaluation Intralesional enhancement kinetics centripetal vs centrifugal Kwantification of enhancement, time-intensity curves multiple T1 fs GE runs (images every 80 sec) over 5-8 min

6 Morphologic evaluation Lesion size, contour, internal architecture Round/Oval, homogeneous, regular contour benign Heterogeneous segmental or spicular contour malignant

7 Dynamic Contrast Enhancement Evaluation Principles of enhancement Invasive lesion Angiogenetic factors Growth of existing capillaries De novo angiogenesis Abnormal configuration: AV- shunts and defective endothelium Enhancement Increased in- and efflux Increased extracellular space Increased extravasation

8 Dynamic Contrast Enhancement Evaluation Signal intensity 120 Time-intensity curves Carcinoom Fibroadenoom Hyperplasie Normaal klierweefsel Spier Time (minutes)

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

10 Dynamic criteria Time-intensity curves Type 2 Type 2 curve Plateau curve 4-6 = peak 1-3 (maximum variation of plateau in delayed part of slope: : 10%) Benign and malignant

11 Dynamic criteria Time-intensity curves Type 3 curve Wash-out curve Usually malignant Type 3

12 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

13 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

14 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

15 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

16 Accurracy Breast MRI False Negatives Invasive Lobular Carcinoma Diffuse infiltration of surrounding tissue ( Indian file configuration) Nutrition via existing capillaries or cellular diffusion

17 Accurracy Breast MRI False Negatives DCIS Tumor inside duct or lobule (intact basal membrane) Nutrition via ductolobular system DCIS

18 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

19 Contra-indications (Breast)-MRI

20 Contra-Indication (Breast)-MRI: Ferromagnetic structures Pacemaker, neurostimulator, hearing device, dental prosthesis, metallic splinter in the eye,

21 Contra-Indication (Breast)-MRI: Claustrophobia Noise 60-90dB 20 minutes

22 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:

23 Contra-Indication (Breast)-MRI: Pregnancy First 3 months pregnancy: avoid MRI

24 No Indication for Breast-MRI

25 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!

26 No Indication for Breast MRI: Screening low-risk patients Screening low-risk patient with dense breasts MRI MX + US

27 No Indication for Breast MRI: Alternative for Biopsy Evaluation suspicious lesion on MX/US MRI Biopsy!

28 Indications Breast-MRI

29 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)

30 Indications Breast MRI Screening High Risk Patients

31 Indications Breast-MRI: Screening High Risk Patients High risk patients <40y: MR/y >40y with dense breasts: MR/y (evt also MX+US/y) Advantages Breast-MRI: Highest sensitivity No radiation

32 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.

33 Indications Breast MRI Preoperative Evaluation

34 Indications Breast-MRI: Preoperative Evaluation After diagnosis unifocal mammacarcinoma Multifocality? Multicentricity? Contralateral breast? (synchronous ca in 5-20%) Chest wall involvement?

35 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

36 Indications Breast-MRI: Preoperative Evaluation Modest specificity of MRI: Only 20% of additional foci are malignant False positives extra biopsy Sometimes only possible with MRguidance Extra time, costs, patient anxiety,

37 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 lifethreatening tumors?

38 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?

39 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

40 Indications Breast MRI Detection Recurrence After Surgery

41 Indications Breast-MRI: Detection Recurrence After Surgery Recurrence rate 1%/year after surgery Scar tissue or recurrence? Enhancement 2 years after completion of treatment is suspicious wait (3) 6 months after surgery wait (12)-18 months after radiation therapy

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

43 Indications Breast MRI Evaluation Neo-adjuvant Chemotherapy

44 Indications Breast-MRI: Evaluation Neoadjuvant Chemotherapy MRI highest accurracy for monitoring chemotherapy Change in (residual) tumor size, signal intensity and contrast kinetics Underestimation possible!

45 Monitoring chemotherapy Underestimation possible!

46 Indications Breast MRI Evaluation Breast Implants

47 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 after reconstruction

48 Prepectoral / Retropectoral Breast Implants

49 Linguine sign

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

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

52 Indications Breast MRI (Discrepancy MX US)

53 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

54 Take home messages

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

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

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

58 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)

59 Take home messages When in doubt first discuss indication with the radiologist Provide thorough clinical information and previous imaging studies (MR/MX/US)

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