Recent advances in MRI Breast and Future Dr.Rattehalli R

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Recent advances in MRI Breast and Future

• Dr.Rattehalli R Ramachandra
• Consultant Radiologist
• University Hospitals Coventry Warwick NHS trust

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Introduction

• Timeline of Breast diagnosis
• Role of MRI Breast
• Recent advances
• Other modalities
• Conclusion

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Breast cancer UK

• Commonest cancer in women
• Accounts for 31 of all cancers in women
• Life time risk for men 1 in 1014
• Life time risk for women 1 in 9
• Ref Cancer research UK Feb 2009

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Timeline of Breast Diagnosis

• 1950s Breast Self Examination
• 1960s BSE Mammography
• 1970s BSE Mammography Thermography
  Ultrasound
• 1980s BSE mammography Better US
• 1990s BSE mammo US MRI
• 2000s Digital mammo US MRI
• 2010?? Digital mammo US MRI MR
  spectroscopyTomosynthesis PEM BSGI

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Spiculate mass left Breast
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Right Breast Screening Mammogram
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Coned view
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US Bx Invasive lobular cancer
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Any more lesions ?
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MRI Breast with contrast
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MRI Breast with contrast and subtraction
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Colour mapping
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MRI Breast 2006 to 2010 April
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Timeline of Breast Diagnosis

• 1950s Breast Self Examination
• 1960s BSE Mammography
• 1970s BSE Mammography Thermography
  Ultrasound
• 1980s BSE mammography Better US
• 1990s BSE mammo US MRI
• 2000s Digital mammo US MRI
• 2010?? Digital mammo US MRI Tomosynthesis
  PEM BSGI

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Sensitivity SpecificityMammogram Vs
Ultrasound Vs MRI
Reference Haitham Elsamaloty et al . AJR 2009
1921142-1148, Increasing the accuracy of
detection of Breast Cancer with 3-T MRI.
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PPV of Mammography for Breast cancer

• For under 50 yrs ranges from 20
• For age 50-69 yrs 60-80

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Sensitivity and Specificity of Annual MRI,
Mammography, Ultrasound and 6 Monthly CBE in High
Risk Women
Cancer Imaging 2005 5(1) 32-38
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MR Vs Mammogram Examples

• Netherlands study
• 1909 high risk patients
• 50 cancers
• 80 detected by MRI
• 33 detected by mammography

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MR Vs Mammogram Examples

• UK
• 649 high risk women
• 35 cancers
• MRI found 77
• Mammography found 40

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MR Vs Mammogram Examples

• Canada
• 236 Women at high risk
• 22 cancers
• MRI found 77
• Mammo found 36

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MR Vs Mammogram Examples

• Bonn
• 529 Women at high risk
• 43 cancers
• MRI found 91
• Mammography found 33

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Breast Ultrasound

• Not a screening test
• Good for lumps
• Good for clarification of abnormalities seen on
  mammography other than calcifications
• Good for taking biopsies

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DIGITAL MAMMOGRAPHY

• DENSE BREASTS
• WOMEN UNDER 50
• PREMENOPAUSAL WOMEN
• EQUAL OR SLIGHTLY REDUCED RADIATION DOSE
• Coventry is now fully digital
• Digital Tomosynthesis reduces the recall rate in
  dense breasts

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Indications

• Staging newly diagnosed breast carcinoma ?
• Lobular cancer staging
• Unknown causes of axillary adenopathy
• Neo adjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Radiation exposure at young age
• Difficult mammogram/ultrasound/physical
  examination, Problem solving

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COMICE Trial Results

• Between 2001 to 2007
• 1625 patients,817 with 807 without MRI
• Re operation with in 6 months was
• 18.8 with MRI 19.3 without MRI
• Result No significant benefit by addition of MRI
  to conventional Triple assessment
• Comparitive effeciveness of MRI in Breast cancer
  trial
• Reference L.Turnbul,Symposium Mammographicum
  2008.Lille, France 06/07/2008, Also Lancet
  13/2/2010

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Indications

• Staging newly diagnosed breast carcinoma ?
• Lobular cancer staging
• Unknown causes of axillary adenopathy
• Neo adjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Difficult mammogram/ultrasound/physical
  examination, Problem solving
• Radiation exposure at young age

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MRI in Invasive Lobular cancer

• MRI accurately assesses the size extent of
  cancer
• Detects cancer on other side
• Can change treatment plan in up to 28 of cases
• NICE guideline

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P W 2006 HISTORY

• 55YRS OLD
• P 3 R4 LUMP IN RIGHT BREAST
• US BIOPSY B5b LOBULAR SINGLE LESION
• MRI TO EXCLUDE ANY OTHER LESION
• OTHERWISE SUITABLE FOR WLE

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Multifocal 3 leisons
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Indications

• Staging newly diagnosed breast carcinoma ?
• Lobular cancer staging
• Unknown causes of axillary adenopathy
• Neo adjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Difficult mammogram/ultrasound/physical
  examination, Problem solving
• Radiation exposure at young age

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Metastatic Nodes in Axilla With No Obvious
Primary in Breast

• lt 2 of patients present with palpable axillary
  nodes and negative mammogram and US
• MRI finds the primary in up to 60-75 of cases
• This should be confirmed by second look US or MR
  guided biopsy

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Indications

• Staging newly diagnosed breast carcinoma ?
• Lobular cancer staging
• Unknown causes of axillary adenopathy
• Neo adjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Difficult mammogram/ultrasound/physical
  examination, Problem solving
• Radiation exposure at young age

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Extra capsular silicon
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Silicon only image. Extra capsular silicon with
fluid collection
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Normal side
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US Extra capsular silicon
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Extra capsular silicon
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Silicon in Right axillary lymph node
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Coronal images to asses overall shape
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Indications

• Staging newly diagnosed breast carcinoma ?
• Lobular cancer staging
• Unknown causes of axillary adenopathy
• Neo adjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Radiation exposure at young age
• Difficult mammogram/ultrasound/physical
  examination, Problem solving

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New ACS Guidelines for Annual MRI Screening in
addition to Mammo(May, 2007)

• Any woman who has greater than 20 lifetime risk
  of developing breast cancer
• (BRACAPRO, GAIL, BOADACEA)
• BRCA mutation and untested relatives
• Prior XRT (bet ages of 10-30)

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NICE Guideline MRI annual surveillance

• From 30-39 yrs
• To women at a 10 year risk gt8
• From 40-49 yrs
• To women at 10 year risk of gt 20 or
• To women at a 10 year risk of gt 12 where
  mammography has shown a dense breast pattern

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Radiation exposure at young age

• Hodgkin's disease treated with Mantle radiation
• Risk of BC increases beginning about 7-8yrs after
  treatment peaking at about 15yrs post treatment
• Younger age at treatment Higher risk
• Many unaware of risk
• Begin intensive screening 6-7 yrs after treatment

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Indications

• Staging newly diagnosed breast carcinoma ?
• Lobular cancer staging
• Unknown causes of axillary adenopathy
• Neo adjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Radiation exposure at young age
• Difficult mammogram/ultrasound/physical
  examination, Problem solving

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Problem solving

• Case 1

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• SH 60 yrs. Recalled from screening for possible
  ASD Right Breast

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• Further views showed normal mammogram.

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• However, US 8mm IDM UOQ Biopsy B5b Invasive DC

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• US localisation for WLE SNB

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MDM

• Specimen X ray normal Breast tissue
• HP No tumour in the specimen
• SNB positive
• Repeat US Post operative changes only with lot
  of oedema and seroma. No tumour seen
• Decision To do MRI to try and Identify the
  tumour

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MRI Seroma with 23x14mm Tumour
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MRI Seroma with 23x14 mm Tumour
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Second look Ultrasound

• Guided by MRI location of the lesion
• Tumour identified by US and localised again
• Tumour excised during ANC
• HP report 22 mm IDC with clear margin

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Occult on Conventional Imaging

• CASE 2

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MC 72yrs

• Clinical P3 nodularity Left Breast
• Normal Mammogram
• Normal Ultrasound
• Clinical core biopsy
• HP Invasive carcinoma mixed Ductal and Lobular
• MDM Decision For MRI to asses exact size

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MRI 53x49mm with axillary nodes 2.3cms
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Surgery

• Mastectomy with axillary node clearance
• HP 50mm Invasive carcinoma mixed Ductal and
  Lobular Grade 2
• 3 out of 13 nodes positive for metastases

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Case 3

• Response to Chemotherapy

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• 44yr SD H/o LIRB.O/E swelling in right breast
  with some inflammatory changes.

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Mammogram Heterogeneously dense breastDiffuse
stromal pattern with no focal mass
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Ultrasound Increased vascularity mixed
echogenicity.IDM in UOQ 2cm from right nipple.
Axillary nodes up to 3 cm Bx IDC
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Pre chemo MRI 80x 43 mm IDM
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MRI After 2 courses of Chemotherapy 6.4x4.5 cm
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Post Chemotherapy 11wks later Few tiny enhancing
nodules
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Post operative finding

• Four foci of residual grade 2 invasive ductal
  carcinoma
• No realistic tumour size can be estimated

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CASE 4

• CLINICAL AND IMAGING DISCREPANCY

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39 yrs JM

• H/o Lump in Left Breast
• O/E 1cm lump in left breast UOQ
• Imaging About 3 cm lump in UOQ
• B5b
• Suitable for WLE
• MDM For MRI to confirm the size

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MRI 7 cm IDM and
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Second lesion found 2cm
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Dynamic graph typical for cancer
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Post contrast colour mappingtreated by mastectomy
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Axillary lymphadenopathy
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LB. 47Yrs.

• Right axillary nodes
• Biopsy Metastatic carcinoma from Breast
• Mammogram Dense breast. Extensive benign changes
  with cysts
• US No obvious primary in the Breast

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Non Contrast T1
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Non contrast T2
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Post Contrast Subtraction images
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Post contrast subtraction
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LF 51yrs

• H/o Suspicious lump in left breast
• Nipple changes
• Fullness
• Ill defined lumpy area inner aspect of left nipple

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Left Mammogram MLO
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Coned compression view
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US Vague area 20mm. Bx B1
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Stereo core Bx B5b Lobular cancer
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MDT

• Patient very reluctant for mastectomy
• For MRI to asses the actual size of lesion
• Exclude multi focal nature

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MRI 60x25mm
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Mammoplasty histology

• 70mm Grade 2 Lobular cancer
• Probably multi focal
• Difficult to asses size
• Lateral margin involved

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Why not screen everybody?????

• Hey, a normal MRI virtually excludes invasive
  breast cancer!

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Limitations of MRI

• False positives
• Overlap of Benign malignant lesions
• Incidental enhancing lesions
• About 30
• Needs further assessment with second look US,Bx,
  ? MR guided

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False Negatives

• Invasive lobular cancer
• Low grade Ductal cancers eg Tubular
• DCIS
• Presents as MC in 73-98
• MRI sensitivity 40-100
• Small lesions lt 3mm difficult to detect
• Enhancing pattern often atypical
• MR spectroscopy may help in future

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MR spectroscopy 4T
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Inappropriate uses of MRI

• Should not be substituted for Mammography or
  Ultrasound
• Should not be used as substitute for a
  histological diagnosis
• No studies proving efficacy of MRI as a screening
  tool in the general population

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Conclusion 1

• MRI is not a screening tool for women over 50yrs
• MRI with Mammogram is good for high risk women
• MRI is indicated for staging in invasive lobular
  cancer
• MRI is not required for routine staging
• MRI should be used as problem solving tool in
  difficult circumstances

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Conclusion 2

• We Await new tools like Tomosynthesis, Improved
  software on Spectroscopy for breast imaging,
• Future CT mammography, BSGI,PEM
• MR Ductography

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Thank you