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
Which Indication For Breast MRI? Breast MRI Contra-Indications No Indications Indications
Breast MRI Bilateral breast coil Prone position Contrast bolus injection (Gadolinium IV)
T Two Water White Breast MRI T1 T2 T1 + Gd sub Cor T1 fs +Gd
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
Morphologic evaluation Lesion size, contour, internal architecture Round/Oval, homogeneous, regular contour benign Heterogeneous segmental or spicular contour malignant
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 180 160 140 120 100 80 60 40 20 0 1 2 3 4 5 6
Dynamic Contrast Enhancement Evaluation Signal intensity 120 Time-intensity curves 100 80 60 40 Carcinoom Fibroadenoom Hyperplasie Normaal klierweefsel Spier 20 0 0 1 2 3 4 5 Time (minutes)
Dynamic criteria Time-intensity curves 160 140 120 100 80 60 40 Type 1 curve Linear curve, continued enhancement Usually benign 20 0 0 1 2 3 4 5 6 Type 1
Dynamic criteria Time-intensity curves 160 140 120 100 80 60 40 20 0 0 1 2 3 4 5 6 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
Dynamic criteria Time-intensity curves 160 140 120 100 80 60 Type 3 curve Wash-out curve Usually malignant 40 20 0 0 1 2 3 4 5 6 Type 3
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
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
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 180 160 140 120 100 80 60 40 20 0 1 2 3 4 5 6
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
Accurracy Breast MRI False Negatives Invasive Lobular Carcinoma Diffuse infiltration of surrounding tissue ( Indian file configuration) Nutrition via existing capillaries or cellular diffusion
Accurracy Breast MRI False Negatives DCIS Tumor inside duct or lobule (intact basal membrane) Nutrition via ductolobular system DCIS
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
Contra-indications (Breast)-MRI
Contra-Indication (Breast)-MRI: Ferromagnetic structures Pacemaker, neurostimulator, hearing device, dental prosthesis, metallic splinter in the eye, http://www.mrisafety.com/list_search.asp
Contra-Indication (Breast)-MRI: Claustrophobia Noise 60-90dB 20 minutes
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: http://www.nephron.com/cgi-bin/cgsi.cgi
Contra-Indication (Breast)-MRI: Pregnancy First 3 months pregnancy: avoid MRI
No Indication for Breast-MRI
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!
No Indication for Breast MRI: Screening low-risk patients Screening low-risk patient with dense breasts MRI MX + US
No Indication for Breast MRI: Alternative for Biopsy Evaluation suspicious lesion on MX/US MRI Biopsy!
Indications Breast-MRI
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)
Indications Breast MRI Screening High Risk Patients
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
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.
Indications Breast MRI Preoperative Evaluation
Indications Breast-MRI: Preoperative Evaluation After diagnosis unifocal mammacarcinoma Multifocality? Multicentricity? Contralateral breast? (synchronous ca in 5-20%) Chest wall involvement?
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
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,
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?
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?
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
Indications Breast MRI Detection Recurrence After Surgery
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
Scar tissue Recent scar (< 12-18m): hypervascular inflammation with strong enhancement Old scar (> 18 m): fibrous hypovascular tissue with few/no enhancement
Indications Breast MRI Evaluation Neo-adjuvant Chemotherapy
Indications Breast-MRI: Evaluation Neoadjuvant Chemotherapy MRI highest accurracy for monitoring chemotherapy Change in (residual) tumor size, signal intensity and contrast kinetics Underestimation possible!
Monitoring chemotherapy Underestimation possible!
Indications Breast MRI Evaluation Breast Implants
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
Prepectoral / Retropectoral Breast Implants
Linguine sign
Indications Breast MRI Axillar adenopathy or metastasis with normal MX and US
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%
Indications Breast MRI (Discrepancy MX US)
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
Take home messages
Take home messages Accurracy Breast MRI for IDCA: Very high sensitivity Modest specificity Very high negative predictive value
Take home messages Contra-indications for (Breast)-MRI Ferromagnetic structures Claustrophobia Severe chronic renal failure Pregnancy <3 months
Take home messages No Indications for Breast MRI Microcalcifications Screening low-risk patients Replacement of biopsy
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)
Take home messages When in doubt first discuss indication with the radiologist Provide thorough clinical information and previous imaging studies (MR/MX/US)