National Diagnostic Imaging Symposium 2013 December 8-12, 2013 Disney s Yacht Club Resort Lake Buena Vista, Florida Self Assessment Module Questions, Answers and References Day SAM Title - Each SAM title is worth 1.0 SAM credit Lecture Titles Faculty DCIS - New Data and Interpretation Breast Imaging: DCIS/MR Guided Monday Methods Harms Biopsy Monday MRGuided Biopsy-Tips and Tricks Butler Monday Monday Breast MR: Preoperative Planning/High Risk Surveillance Steven Harms, MD DCIS New Data and Interpretation Methods Preoperative Planning and the Controversies of Breast MR High Risk Surveillance - Contributions of Breast MR Otto Porter 1. Studies show that 90% of DCIS discovered on mammography is calcified. Of the incidental DCIS discovered on pathology, how much is calcified? A. 5% B. 15% C. 30% D. 50% E. 75% Answer: C Menell J. Breast J 2005; 6:382. 2. On MRI, DCIS is most likely to appear as: A. Non-mass enhancement B. Irregular mass C. Spiculated mass D. Round or oval mass E. Calcification ANSWER: A Reference Liberman AJR 2002; 179:171, Gutierrez AJR 2009; 193:994, Baltzer AJR 2010: 194:1658 3. The MONET trial showed that patients undergoing breast MR had a higher rate of positive margins. The MONET trial showed a high rate of false negatives due to missed National Diagnostic Imaging Symposium 2013 SAM - Breast MRI 1
A. Infiltraing ductal carcinoma B. Infiltrating lobular carcinoma C. Ductal carcinoma in situ D. Atypical ductal hyperplasia E. Lobular carcinoma in situ ANSWER: C Reference Peters Eur J Cancer 2011; 47:879. 4. DCIS can be reliably detected and characterized on MRI if which technical goal is achieved A. Better dynamic resolution (shorter scans) B. Inversion recovery fat suppression C. Use of images without fat suppression D. Higher resolution and better contrast E. Parallel imaging ANSWER: D Reference Harms Seminars in Breast Disease 2008; 11:51. 5. The most common cause of false positive MRI: A. Fibroadenoma B. Papilloma C. LCIS D. Hormone induced enhancement E. Benign proliferative change ANSWER: E Liberman AJR 2002; 179:171, Gutierrez AJR 2009; 193:994, Baltzer AJR 2010: 194:1658 National Diagnostic Imaging Symposium 2013 SAM - Breast MRI 2
Reni Butler, MD MRI-Guided Breast Biopsy - Tips and Tricks 1. Which BI-RADS 4 MRI-detected lesion is most likely to have an ultrasound correlate? A. 12 mm area of focal heterogeneous NME B. 7 mm area of linear branching enhancement C. 11 mm irregular mass D. 6 mm circumscribed mass MRI- detected lesion features which have been associated with a higher likelihood of a sonographic correlate in the literature include mass vs. nonmass enhancement, larger size, and higher level of suspicion. 1. Meissnitzer M, Dershaw DD, Lee C, Morris E. Targeted ultrasound of the breast in women with abnormal MRI findings for whom biopsy has been recommended.ajr 2009;193(4):1025-1029 2. Abe H, Schmidt RA, Shah RN, et al. MR-directed ("Second-Look") ultrasound examination for breast lesions detected initially on MRI: MR and sonographic findings. AJR 2010;194(2):370-377 2. Which of the following techniques is helpful for targeting a lateral posterior lesion? A. Inserting padding between grid and breast, as in the washcloth technique B. Placing the patient in a lateral decubitus position C. Bringing the patients arms down by her side D. Cushioning the biopsy table to increase patient comfort Choice A is a technique useful in targeting an anterior lesion, while choices C and D are the opposite of additional techniques useful for targeting posterior lesions. 1. Eby P, Lehman C. Magnetic resonance imaging--guided breast interventions.topics in magnetic resonance imaging 2008;19(3):151-162 3. A 45 year-old BRCA+ woman presents for MRI biopsy but the suspicious lesion seen on her diagnostic MRI is not reproduced. What is the appropriate management? A. Reschedule the patient for MRI-guided biopsy at a different phase of her menstrual cycle B. Recommend surgical excision of the region C. Repeat the MRI study in 2-3 months D. Recommend 6 month follow-up Cancellation of MRI-guided biopsy due to non-visualization occurs in 8-12% of cases. If a lesion cannot be visualized in spite of technically adequate imaging in both the initial and delayed phases of enhancement, 6 month follow-up is appropriate. National Diagnostic Imaging Symposium 2013 SAM - Breast MRI 3
1. Brennan S, Sung J, Dershaw DD, Liberman L, Morris E. Cancellation of MR imaging guided breast biopsy due to lesion nonvisualization: frequency and follow-up. Radiology 2011;261(1):92-99 2. Perlet C, Hewang-Kobruner SH, Heinig A, et al. Magnetic resonance-guided, vacuumassisted breast biopsy: results from a European multicenter study of 538 lesions. Cancer 2006;106(5)982-990 4. A high-risk patient has a 7 mm mass with irregular margins and wash-out on screening MRI. MRI-guided biopsy reveals benign fibrocystic change. What is the appropriate management recommendation? A. 6 month follow-up B. 12 month follow-up C. Surgical excision D. Second-look ultrasound The histology of benign fibrocystic change does not explain the presence of a mass with suspicious morphologic and kinetic features. This diagnosis is, therefore, discordant and warrants surgical excision. 1. Eby P, Lehman C. Magnetic resonance imaging--guided breast interventions. Topics in magnetic resonance imaging 2008;19(3):151-162 2. Mahoney M, Newell M. Breast Intervention How I Do It. Radiology 2013;268(1)12-24 National Diagnostic Imaging Symposium 2013 SAM - Breast MRI 4
Pamela M. Otto, MD, FACR Preoperative Planning and the Controversies of Breast MR 1. Preoperative MRI of the breast A. Improves surgical treatment by increasing the rate of negative margins at time of initial surgery. B. Decreases conversion from breast conservation surgery to mastectomy. C. Reduces recurrence of breast cancer in the contralateral breast. D. Causes an increase in both ipsilateral and contralateral mastectomy rates. E. Increases disease free intervals. Correct answer is d. Pre-operative MRI of the breast increases the rate of both ipsilateral and contralateral mastectomy rates from 18.2% in patients with no MRI to 25.5% in patients with preo-operative MRI. N. Houssami, M. Morrow (2013) Does preoperative MRI improve clinical outcomes in breast cancer. Breast Cancer Management 2(2); 115-122. 2. Diagnostic MRI of the breast is helpful in the evaluation of patients with metastatic cancer to the lymph nodes in order to find the occult primary tumor and thus A. Determine the chemotherapeutic approach to the patient. B. Allow for lumpectomy vs mastectomy. C. Delete the need for radiation therapy. D. Evaluate for contralateral disease. E. Determine need for axillary lymph node dissection. Correct answer is b. If the primary tumor is found by MRI, patient is then a candidate for lumpectomy instead of mastectomy. NCCN guidelines, May 15, 2013, 3.2013, MS-62 3. In the study by Mann, et al, it was found that in patients diagnosed with infiltrating lobular cancer A. The re-excision rate due to positive margins was the same in patients who recieved preoperative MRI compared to those with no pre-operative MRI. B. MRI had a high false negative rate. C. The definition of margins and extent of disease was more difficult to determine when compared to invasive ductal carcinoma. D. The re-excision rate due to positive margins was significantly lower in patients who underwent preoperative MRI. E. MRI decreased mastectomy rates. Correct answer is d. The re-excision rates in patients without MRI was 27% compared to 9% in patients who underwent pre-operative MRI. Mann, et al. Breast Cancer Res Treat (2010) 119: 415-422 National Diagnostic Imaging Symposium 2013 SAM - Breast MRI 5
Bruce A. Porter, MD, FACR High Risk Surveillance- Breast MR 1. Breast cancer gene (BRCA 1 & 2) carriers have what lifetime risk of developing breast cancer? A. 20-24% B. 35% C. 60% D. >95% ANSWER: C NCI: http://www.cancer.gov/cancertopics/factsheet/risk/brca. 2. Which of these is associated with breast cancer risk approaching that of the BrCa positive patients by age 55? A. Colon cancer. B. History of radiation treated lymphoma. C. Myelodysplastic syndrome. D. Malignant melanoma. ANSWER: B If treated between ages 10-30; greater near menarche and proportional to breast dose. Newer techniques likely decrease risk. Travis LB, Hill D, Dores GM, et al, Cumulative Absolute Breast Cancer Risk for Young Women Treated for Hodgkin Lymphoma, J Natl Cancer Inst 2005; 97, 1428-1437. 3. In newly diagnosed breast cancer the negative predictive value of breast MR for the contralateral breast has been shown to be: A. 35% B. 60% C. 92% D. 99% ANSWER: B Lehman, Gatsonis c, Kuhl C,et. al., MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer, NEJM 2007;356, 1295-1303 National Diagnostic Imaging Symposium 2013 SAM - Breast MRI 6