BREAST MRI. Elizabeth A. Rafferty, M.D. Avon Comprehensive Breast Center Massachusetts General Hospital Harvard Medical School
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1 BREAST MRI Elizabeth A. Rafferty, M.D. Avon Comprehensive Breast Center Massachusetts General Hospital Harvard Medical School
2 BREAST MRI Any assessment of the breast parenchyma requires the administration of intravenous gadolinium.
3 BREAST MRI: ENHANCEMENT Tumor angiogenesis Tumor-incited neovascularity Disorganized ingrowth of vessels Increased permeability With injection of contrast translates to enhanced and accelerated deposition of contrast in the region of the tumor (wash-in) as well as accelerated dissipation of the contrast (wash-out)
4 BREAST MRI Diagnostic applications Screening applications
5 BREAST MRI Diagnostic applications Screening applications
6 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
7 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
8 BREAST MRI: INDEX LESION Assessment of the index lesion Invasive carcinoma Ductal Lobular Ductal carcinoma in situ Assessment for additional foci of malignancy Multifocal Multicentric Assessment of the pectoral muscle and chest wall Evaluation of skin and nipple changes
9 BREAST MRI: INDEX LESION Assessment of the index lesion Invasive carcinoma Ductal Lobular Ductal carcinoma in situ Assessment for additional foci of malignancy Multifocal Multicentric Assessment of the pectoral muscle and chest wall Evaluation of skin and nipple changes
10 BREAST MRI: INDEX LESION Invasive carcinoma ~ 90% ductal ~10% lobular
11 BREAST MRI: INDEX LESION Invasive ductal carcinoma MRI sensitivity for detection ~ 100% Invasive lobular carcinoma MRI sensitivity < 100% MRI presentation of ILC is more variable than the MRI presentation of IDC
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14 BREAST MRI: INDEX LESION Invasive ductal carcinoma MRI sensitivity for detection ~ 100% Invasive lobular carcinoma MRI sensitivity < 100% MRI presentation of ILC is more variable than the MRI presentation of IDC
15 BREAST MRI: INDEX LESION Invasive lobular carcinoma High association with multifocality and multicentricity Synchronous contralateral cancer also more common than seen in IDC Integration of mammographic, sonographic, MRI and clinical findings is critical for optimal analysis of size and extent of lesion
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22 BREAST MRI: INDEX LESION Assessment of the index lesion Invasive carcinoma Ductal Lobular Ductal carcinoma in situ Assessment for additional foci of malignancy Multifocal Multicentric Assessment of the pectoral muscle and chest wall Evaluation of skin and nipple changes
23 BREAST MRI: INDEX LESION Ductal carcinoma in situ ~ 1/3 of breast cancer Detection by MRI? Initial studies suggested 25-50% sensitivity Mid-late 90s showed ~ 75% sensitivity Latest data suggests ~ 90% sensitivity
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30 BREAST MRI: INDEX LESION Assessment of the index lesion Invasive carcinoma Ductal Lobular Ductal carcinoma in situ Assessment for additional foci of malignancy Multifocal Multicentric Assessment of the pectoral muscle and chest wall Evaluation of skin and nipple changes
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36 UTILITY OF MRI IN BCT PATIENTS Solin et al. Retrospective cohort study evaluating relationship of breast MRI to outcomes after BCT (with XRT) for women with Stage 0, I or II disease 756 women from ; 215 (28%) had breast MRI No difference in local failure (3% vs 4%); freedom from distant metastases (89% vs 92%) or overall survival (86% vs 87%) Conclusion: Use of breast MRI was not associated with improved outcomes in women undergoing BCT Solin LJ et al. J Clin Oncol; 26:
37 UTILITY OF MRI IN BCT PATIENTS Solin et al. : Limitations Older technology Did not evaluate why patients were selected to undergo breast MRI (younger patients; larger tumors; no correlation with other imaging) Did not evaluate how many women had alteration in their surgical plan (e.g. wider resection) or did not undergo BCT due to the results of the MRI May not have been powered adequately to show a difference (n=215) Solin LJ et al. J Clin Oncol; 26:
38 OVERDIAGNOSIS / OVERTREATMENT Comparative Effectiveness of MRI in Breast Cancer (COMICE): Randomized controlled trial 45 centers in the UK participated 1623 women with biopsy-proven cancer scheduled for wide excision were enrolled Randomly assigned to receive pre-operative MRI (n=816) or no further imaging (n=807) Primary endpoint: number of patients needing reoperation or mastectomy within 6 months Turnbull L, et al. Lancet 2010; 375:
39 OVERDIAGNOSIS / OVERTREATMENT Comparative Effectiveness of MRI in Breast Cancer (COMICE): Addition of MRI to conventional pre-operative evaluation (mammography, US, clinical exam, bx) did not reduce the re-operation rate 153 (19%) required re-operation in the MRI group 156 (19%) required re-operation in the non-mri group Concluded that MRI might be unnecessary in preoperative patients as it does not reduce re-operation rates No plan was made to track recurrence in the population Turnbull L, et al. Lancet 2010; 375:
40 OVERDIAGNOSIS / OVERTREATMENT Response to COMICE: The study quotes a baseline re-excision rate of 10%, which is very low compared with tertiary cancer centers in the U.S. (20-40% re-excision rate) The histologic margins were very wide and the volume of tissue excised large compared with U.S. tertiary cancer centers where effort is made to excise the smallest volume of tissue possible MRI may have little to add with such large initial excisions
41 OVERDIAGNOSIS / OVERTREATMENT Response to COMICE: 16/58 women (27.6%) underwent pathologically avoidable mastectomies in the MRI group, but only 3 of these had a documented biopsy based on the MRI Was MR-guided intervention not available or utilized? What were the biopsy results for the 3 women undergoing bx leading to the avoidable mastectomies? Changing surgical management without pathologic confirmation dilutes the value of the MRI and is not the standard of care in the U.S.
42 OVERDIAGNOSIS / OVERTREATMENT Response to COMICE: The rate of detection of occult contralateral cancer in the COMICE cohort was 1.6% (13/816). Well below the contralateral detection rates reported in the US Raises questions about the quality of the imaging or interpretation
43 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
44 MRI OF THE CONTRALATERAL BREAST IN WOMEN WITH BREAST CANCER Biopsies PPV of Biopsy MRI-only CA Investigator women No. % No. % No. % Reiber /34 9 Fischer /363 4 Kuhl / /710 6 Liberman / /223 5 Lee / /182 3
45 BREAST MRI: SCREENING Lehman et al. NEJM 2007;356:
46 BREAST MRI: CONTRALATERAL BREAST Lehman et al. 969 women with newly diagnosed cancer and no evidence of contralateral disease on mammography or clinical exam underwent MRI Contralateral cancer was dx in 30/969 women (3.1%) Lehman et al. NEJM 2007;356:
47 BREAST MRI: CONTRALATERAL BREAST Lehman et al. Sensitivity: 91% Specificity: 88% NPV of MRI: 99% Biopsy recommended: 12.5% Yield at biopsy: 24.8% Lehman et al. NEJM 2007;356:
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52 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
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59 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
60 BEFORE THERAPY AFTER THERAPY NEOADJUVANT CHEMOTHERAPY
61 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
62 BREAST MRI: POSITIVE MARGINS CANNOT predict residual microscopic disease Role is to evaluate for macroscopic residual disease Can help direct focally wider re-excision, particularly if breast volume or location of tumor puts conservation in jeopardy with re-excision Can identify previously unsuspected multifocal, multicentric, or contralateral disease
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68 BREAST MRI: INDICATIONS Evaluation of tumor extent Ipsilateral breast Contralateral breast Metastatic axillary node of unknown primary origin in setting of a negative mammogram Monitoring response to neoadjuvant chemotherapy Assessing for residual tumor after resection with positive margins Evaluation for tumor recurrence
69 BREAST MRI: RECURRENCE Post-treatment changes (surgical and radiation therapy) generate patchy diffuse enhancement during the first year During the next 6 months treatment-related enhancement dissipates Only ~ 5% of women have significant treatmentrelated enhancement which persists > 18 months after treatment
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72 BREAST MRI Diagnostic applications Screening applications
73 BREAST MRI: INDICATIONS Screening of high risk women??
74 BREAST MRI: SCREENING Kriege et al 1909 women with lifetime breast cancer risk of 15% or more enrolled 358 BRCA1 or 2 carriers Underwent screening CBE every 6 mos. Annual mammography Annual MRI Kriege et al. NEJM. July 2004
75 BREAST MRI: SCREENING Kriege et al From 11/1/99 through 10/1/03: 51 malignancies detected 44 invasive cancers 6 DCIS 1 NHL Overall cancer detection rate 9.5/1000 In mutation carriers: 26.5/1000 Kriege et al. NEJM. July 2004
76 BREAST MRI: SCREENING Kriege et al From 11/1/99 through 10/1/03: 51 malignancies detected 44 invasive cancers 6 DCIS 1 NHL Overall cancer detection rate 9.5/1000 In mutation carriers: 26.5/1000 Kriege et al. NEJM. July 2004
77 BREAST MRI: SCREENING Kriege et al 45 cancers 22 seen on MRI only 10 seen on MRI and mammography 8 seen only on mammography 4 interval cancers 1 cancer detected on CBE only Kriege et al. NEJM. July 2004
78 BREAST MRI: SCREENING Kriege et al 45 cancers 22 seen on MRI only 10 seen on MRI and mammography 8 seen only on mammography 4 interval cancers 1 cancer detected on CBE only Kriege et al. NEJM. July 2004
79 BREAST MRI: SCREENING Kriege et al 45 cancers 22 seen on MRI only 10 seen on MRI and mammography 8 seen only on mammography 4 interval cancers 1 cancer detected on CBE only Kriege et al. NEJM. July 2004
80 BREAST MRI: SCREENING Kuhl et al Compared efficacy of mammography, US, and MRI in asymptomatic cohort of women with at least 20% lifetime risk of breast CA 529 women underwent 1542 surveillance rounds Mean follow-up 5.3 years Kuhl et al. JCO. Nov. 2005
81 BREAST MRI: SCREENING Kuhl et al 43 cancers were identified 34 invasive 9 DCIS Kuhl et al. JCO. Nov. 2005
82 BREAST MRI: SCREENING Kuhl et al. JCO. Nov. 2005
83 BREAST MRI: SCREENING Kuhl et al. JCO. Nov. 2005
84 BREAST MRI: SCREENING Kuhl et al. JCO. Nov. 2005
85 BREAST MRI: SCREENING Kuhl et al. JCO. Nov. 2005
86 BREAST MRI: SCREENING Kuhl et al. JCO. Nov. 2005
87 BREAST MRI: SCREENING Kuhl et al. JCO. Nov. 2005
88 HIGH-RISK SCREENING WITH BREAST MRI: PUBLISHED RESULTS Biopsies PPV Cancer % DCIS Investigator women No. % No. % No. % No. % Tilanus /9 33 3/ /3 0 Lo / / Warner / / /4 0 Stoutjesdijk / / /8 25 Sardanelli /8 88 7/ /7 43 Morris / / /14 57 Kuhl / / /6 17 TOTAL / / /42 33
89 HIGH-RISK SCREENING WITH BREAST MRI: PUBLISHED RESULTS Biopsies PPV Cancer % DCIS Investigator women No. % No. % No. % No. % Tilanus /9 33 3/ /3 0 Lo / / Warner / / /4 0 Stoutjesdijk / / /8 25 Sardanelli /8 88 7/ /7 43 Morris / / /14 57 Kuhl / / /6 17 TOTAL / / /42 33
90 HIGH-RISK SCREENING WITH BREAST MRI: PUBLISHED RESULTS Biopsies PPV Cancer % DCIS Investigator women No. % No. % No. % No. % Tilanus /9 33 3/ /3 0 Lo / / Warner / / /4 0 Stoutjesdijk / / /8 25 Sardanelli /8 88 7/ /7 43 Morris / / /14 57 Kuhl / / /6 17 TOTAL / / /42 33
91 HIGH-RISK SCREENING WITH BREAST MRI: PUBLISHED RESULTS Biopsies PPV Cancer % DCIS Investigator women No. % No. % No. % No. % Tilanus /9 33 3/ /3 0 Lo / / Warner / / /4 0 Stoutjesdijk / / /8 25 Sardanelli /8 88 7/ /7 43 Morris / / /14 57 Kuhl / / /6 17 TOTAL / / /42 33
92 HIGH-RISK SCREENING WITH BREAST MRI: PUBLISHED RESULTS Biopsies PPV Cancer % DCIS Investigator women No. % No. % No. % No. % Tilanus /9 33 3/ /3 0 Lo / / Warner / / /4 0 Stoutjesdijk / / /8 25 Sardanelli /8 88 7/ /7 43 Morris / / /14 57 Kuhl / / /6 17 TOTAL / / /42 33
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96 BREAST MRI: SCREENING Saslow et al. CA Cancer J Clin 2007;57: 75-89
97 BREAST MRI: SCREENING Saslow et al. CA Cancer J Clin 2007;57: 75-89
98 BREAST MRI: SCREENING Saslow et al. CA Cancer J Clin 2007;57: 75-89
99 BREAST MRI: SCREENING Saslow et al. CA Cancer J Clin 2007;57: 75-89
100 BREAST MRI: SCREENING Saslow et al. CA Cancer J Clin 2007;57: 75-89
101 BREAST MRI: SCREENING Saslow et al. CA Cancer J Clin 2007;57: 75-89
102 IMPLEMENTING BREAST MRI High sensitivity but limited specificity May be of particular utility in patients with ILC Examination of choice in patients with metastatic axillary node of probable breast primary Most accurate imaging modality for assessing response to neoadjuvant chemotherapy NOT reliable for residual microscopic tumor
103 IMPLEMENTING BREAST MRI High sensitivity but limited specificity May be of particular utility in patients with ILC Examination of choice in patients with metastatic axillary node of probable breast primary Most accurate imaging modality for assessing response to neoadjuvant chemotherapy NOT reliable for residual microscopic tumor
104 IMPLEMENTING BREAST MRI High sensitivity but limited specificity May be of particular utility in patients with ILC Examination of choice in patients with metastatic axillary node of probable breast primary Most accurate imaging modality for assessing response to neoadjuvant chemotherapy NOT reliable for residual microscopic tumor
105 IMPLEMENTING BREAST MRI High sensitivity but limited specificity May be of particular utility in patients with ILC Examination of choice in patients with metastatic axillary node of probable breast primary Most accurate imaging modality for assessing response to neoadjuvant chemotherapy NOT reliable for residual microscopic tumor
106 IMPLEMENTING BREAST MRI High sensitivity but limited specificity May be of particular utility in patients with ILC Examination of choice in patients with metastatic axillary node of probable breast primary Most accurate imaging modality for assessing response to neoadjuvant chemotherapy NOT reliable for residual microscopic tumor
107 IMPLEMENTING BREAST MRI The parameters used to define high risk will determine the cancer detection rate in the screening setting Patients should be aware of the possibility of recommendations for follow-up, additional imaging evaluation, and biopsy MRI should not be viewed as an adjunct to, not a substitute for, mammography
108 IMPLEMENTING BREAST MRI The parameters used to define high risk will determine the cancer detection rate in the screening setting Patients should be aware of the possibility of recommendations for follow-up, additional imaging evaluation, and biopsy MRI should not be viewed as an adjunct to, not a substitute for, mammography
109 IMPLEMENTING BREAST MRI The parameters used to define high risk will determine the cancer detection rate in the screening setting Patients should be aware of the possibility of recommendations for follow-up, additional imaging evaluation, and biopsy MRI should be viewed as an adjunct to, not a substitute for, mammography
BREAST MRI. Elizabeth A. Rafferty, M.D. Avon Comprehensive Breast Center Massachusetts General Hospital Harvard Medical School
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