Contrast-enhanced Breast MRI RSSA 2013 Prof. dr. Maurice van den Bosch University Medical Center Utrecht, the Netherlands
Index 1) Breast cancer 2) Why MRI of the breast 3) Technique 4) Interpretation of breast MRI 5) Clinical indications 6) 7T High Resolution Breast MRI
Breast cancer - Most common type of cancer in women - Diagnosis: 10.000 women / year - Early detection favors prognosis - Different diagnostic strategies - Mammography is 1 st modality: - Sensitivity: 69-81% - Specificity: 40-60% - Decreased accuracy in dense breasts
Why MRI of the breast - MRI is extremely sensitive to enhancement by contrast regardless of breast density or composition - Tumor angiogenesis leads to preferential enhancement of cancers with intravenous contrast - Sensitivity of MRI for invasive tumors is high > 95%
Technique - Patient is prone positioned - Dedicated 8 channel phased-array breast coil - 1.5T or 3.0T closed bore magnet
Technique - Standard MRI protocol bilateral breast imaging: m SURVEY (MST) SynBody (Refscan) T1 FFE (Tra) T2 SPAIR (Tra) T1 DYN THRIVE (Tra) T1 3Dhr postgd (Tra)
Technique 3.0 T MRI protocol UMC Utrecht: T1 3D FFE DYN (axial) (FOV 340 mm, matrix 352x384 matrix, 1.0 mm slice thickness, gap: 0, TR/TE shortest/shortest, flip angle: 30, scan duration each dynamic scan: 50 sec, started after intravenous bolus injection of 0.1 mmol/kg Magnevist), 8 dynamic series
Interpretation of breast MRI American College of Radiology BI-RADS MRI lexicon Description of a mass: - Margin: smooth, irregular, spiculated - Shape: round, oval, lobulated, stellate - Enhancement: homogeneous, heterogeneous, rim - Associated findings: edema or skin thickening Lesion diagnosis working group, JMRI 1999,10:982-90
Interpretation of breast MRI American College of Radiology BI-RADS MRI lexicon Enhancement kinetics: - Initial enhancement (within the first 2 minutes): slow, medium or fast - Delayed phase: persistent, plateau, or washout
Interpretation of breast MRI Spiculated homogeneous enhancing mass, rapid initial enhancement followed by washout: BI-RADS MRI: V PA: invasive ductal carcinoma
Interpretation of breast MRI Homogeneous enhancing oval mass with smooth borders. Slow initial enhancement followed by persistent: BI-RADS MRI: II PA: fibroadenoma
Clinical indications 1) Screening of high risk women 2) Diagnosis of indeterminate breast lesions 3) Pre-operative staging of known breast cancer 4) Imaging of patients with positive axillary node 5) Evaluation of response to neo-adjuvant chemotherapy
Clinical indications Screening of high risk patient: PA: invasive adenoma carcinoma
Clinical indications Diagnosis of indeterminate mammographic lesion MRI-guided localization, PA: Fibroadenoma
Clinical indications Staging of known breast malignancy PA: skeletal metastasis: 2.3x1.5 cm
Clinical indications Positive axillary lymph node PA: invasive ductal carcinoma 6x5 mm
Clinical indications Response to neo-adjuvant chemotherapy Before 6 FEC After chemotherapy
Clinical indications Staging of known breast malignancy (MONET trial) PA: multicentric invasive ductal carcinoma
MONET Randomized Clinical Trial
MONET Randomized Clinical Trial Purpose: Does CE-MRI in addition to mammography/us in patients with non-palpable lesions improve breast cancer management
MONET Trial Methods - 418 women with nonpalpable 3-5 lesions were randomized - Group A: N=211 mammography, US, LCNB (routine care) - Group B: N=207 routine care + CE-MRI prior to biopsy - Patients with malignancy underwent surgery
MONET Trial Methods Primary endpoint: Rate of additional surgical procedures: a) Re-excisions b) Conversions to Mastectomy
MONET Results
MONET Results
MONET Results - The primary BCS rate was similar in both groups: 66% controls vs 68% MRI group - Number of re-excisions due to positive margins BCS 6/50 (12%) controls vs 18/53 (34%) MRI group (p=0.008) - The numbers of conversions to mastectomy did not differ
MONET Trial Conclusion MRI in addition to routine clinical care was paradoxically associated with an increased reexcision rate MRI should not be used routinely for preoperative work-up in these patients
MRI-guided biopsy - MRI can detect occult breast lesions - 10-20% of patients with breast cancer have multifocal disease - 15% of high risk patients have IEL s - Always second look ultrasound - MRI guided VAB has been developed to allow selective tissue sampling of MRI only lesions:
MRI-guided biopsy - MRI can detect occult breast lesions - 10-20% of patients with breast cancer have multifocal disease - 15% of high risk patients have IEL s - Always second look ultrasound - MRI guided VAB has been developed to allow selective tissue sampling of MRI only lesions:
MRI-guided biopsies
MRI-guided biopsies
New developments 7.0T High Field Breast Imaging: Promises: - Higher field strength results in linearly increased SNR - Higher SNR enables increased spatial resolution (DCIS) - Higher SNR can be exchanged for faster scanning techniques - More sensitive for phase changes (calcification detection)
7.0T Feasibility Study - We started a feasibility study comparing 3T with 7T - Included were women >18 yrs with BIRADS 4 or 5 mass lesions
7.0T Feasibility Study - Unilateral two channel breast coil
7.0T Feasibility Study - Scan protocol T1w_GRE dynamic (7:25min) 7x T1w GRE Injection of Gd after 1 st series FA 10, TR/TE 5.0/2.0 ms, FOV 160 3 mm 3 Voxel size 1.0x1.0x2.0 mm 3 Temporal resolution 63s T1w_GRE Highres (13:30min) FA 12, TR/TE 7.0/2.9 ms, FOV 120 3 mm 3 Voxel size 0.45x0.57x0.45 mm 3
7.0T Feasibility Study: methods Two radiologists Dynamic series - Image quality excellent / good / sufficient / insufficient - Lesion identification + BI-RADS-MRI High-resolution imaging - Added value none / increased reader confidence / change in interpretation / other Invasive ductal carcinoma
7.0T Feasibility Study: Results 20 women with 23 lesions BI-RADS 4 n=7 BI-RADS 5 n=16 19 malignant invasive ductal carcinoma n=12 invasive lobular carcinoma n=2 invasive ductulolubular carcinoma n=5 4 non-malignant cyst n=2 slerosis n=1 radial scar n=1
7.0T Feasibility Study: Case T1w GRE dynamic pre-contrast T1w GRE dynamic post-contrast T1w GRE high resolution BI-RADS-MRI V Pathology: IDC Enhancement (%) 500 450 400 350 300 250 200 150 100 50 0 1 2 3 4 5 6 7 Dynamic series (no.)
7.0T Feasibility Study: Results Image quality dynamic series excellent n=1 (R1) n=0 (R2) good n=10 (R1) n=12 (R2) sufficient n=8 (R1) n=8 (R2) insufficient n=1 (R1) n=0 (R2) Lesion identification + BI-RADS-MRI analysis - All malignant lesions + 1 non-malignant lesion identified - 3 non-malignant lesions were not identified
7.0T Feasibility Study: Results HR scans R1 R2 None 12% (2/17) 29% (5/17) Increased confidence 88% (15/17) 59% (10/17) Change in interpretation 18% (3/17) 41% (7/17) Other 0% (0/17) 0% (0/17)
7.0T Feasibility Study: Challenges - B1 inhomogeneity (Spin echo imaging) - B0 inhomogeneity (Uneven fat-suppression) - Field of view (Unilateral imaging)
Conclusion - Clear indications for anatomical breast imaging at 3T - Imaging and biopsy should be available - Imaging at 7.0T: - Is feasible - High spatial resolution
Thank you for your attention