Breast MRI

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Breast MRI

• Rama Suresh M.D.
• Medical Oncology

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Indications

• Lesion characterizations
• Mammographically dense breast
• Scar vs recurrent cancer
• Silicone augmented breast
• Neoadjuvant chemo extent of disease
• Infiltrating lobular cancer extent of disease
• Infiltrating ductal cancer extent of disease
• Axillary adenopathy primary unknown
• Post tissue reconstructon recurrence
• Implant integrity/ rupture

ACR practice guideline
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Indications

• Invasion to deep fascia
• Contra lateral breast cancer
• Post lumpectomy residual disease close margin
  on path
• Screening high risk patients for breast cancer
• Recurrence of cancer when other modalities
  inconclusive

ACR practice guideline
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Contraindications

• Cardiac pacemakers,
• Ferromagnetic intracranial aneurysm clips
• Neurostimulators
• Cochlear implants
• Ferromagnetic implants, devices, foreign bodies,
  electronic devices.

ACR practice guideline
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Pregnancy/Lactation

• No known adverse effects
• Gadolinium
• does cross placenta into fetus
• minimally secreted in breast milk

ACR practice guideline
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Recommendations for Breast MRI Screening as an
Adjunct to Mammography
CA Cancer J Clin 57 75-89
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Recommendations for Breast MRI Screening as an
Adjunct to Mammography

• Insufficient Evidence to Recommend for or Against
  MRI Screening    
• Lifetime risk 1520, as defined by BRCAPRO or
  other models that are largely dependent on family
  history   
• Lobular carcinoma in situ (LCIS) or atypical
  lobular hyperplasia (ALH)   
• Atypical ductal hyperplasia (ADH)   
• Heterogeneously or extremely dense breast on
  mammography   
• Women with a personal history of breast cancer,
  including ductal carcinoma in situ (DCIS)
• Recommend Against MRI Screening (Based on Expert
  Consensus Opinion)   
• Women at lt15 lifetime risk

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Cost effectivenessannual MRI plus mammography

• Estimated QALY
• Ages 35 to 54
• BRCA 1 - 55,420
• BRCA 2 - 130,695
• Dense breast
• BRCA 1 - 41,183
• BRCA 2 - 98,454

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Cost effectiveness-increment cost per cancer
detected

• 50 risk of BRCA mutation
• 50,911
• Known mutation carrier
• 27,544

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Cost effectiveness Screening mammogram

• Ages 50 to 69 years
• 21 400
• Ages 40 to 49 years
• 105 000

Annals of Internal Medicine 127 (11) 955-965,
1997
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MRI Evaluation of the Contralateral Breast in
Women with Recently Diagnosed Breast
Cancer Constance D. Lehman, M.D., Ph.D.,
Constantine Gatsonis, Ph.D., Christiane K. Kuhl,
M.D., R. Edward Hendrick, Ph.D., Etta D. Pisano,
M.D., Lucy Hanna, M.S., Sue Peacock, M.S.,
Stanley F. Smazal, M.D., Daniel D. Maki, M.D.,
Thomas B. Julian, M.D., Elizabeth R. DePeri,
M.D., David A. Bluemke, M.D., Ph.D., Mitchell D.
Schnall, M.D., Ph.D., for the ACRIN Trial 6667
Investigators Group
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Methods

• 4-1-2003 to 6-10-2004
• 1007 women
• 25 sites
• 1 year follow up

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Inclusion criteria

• 18 years or older with diagnosis of breast cancer
  within 60 days
• Contralateral breast clinical exam and mammogram
  negative within 90 days

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Exclusion criteria

• MRI within 12 months
• Pregnancy
• Contraindication to MRI
• Chemotherapy or hormonal therapy for breast
  cancer within 6 months

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MRI technique

• Dynamic contrast enhanced 3D MRI
• 1.5 T magnet
• Dedicated breast surface coil
• One image before and two images after contrast (4
  min and 8 min post contrast injection

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ACR BI-RADS scoring

• 0- incomplete
• 1-negative 0
• 2-Benign 0
• 3-probably benign lt 2
• 4-suspicious 2-75
• 5-highly suggestive gt 75
• Positive for cancer biopsy confirmation within
  1 year

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Objectives

• Primary Diagnostic yield of breast MRI
• Secondary
• sensitivity, specificity, PPV/NPV of MRI
• positive biopsy rate
• ROC curve
• Assessment of these according to mammographic
  density, menopausal status, type of cancer

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Results

• 33/969 positive for contralateral breast cancer
• 30 MRI diagnosed (3.1)
• 1 mastectomy specimen BIRADS 3
• DCIS
• 2 prophylactic mastectomy BIRADS 1
• DCIS

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Primary endpoint

• Biopsy recommended 135/969 13.9
• Biopsy done 121/969 12.5
• Cancer diagnosed 30/121 24.8
• Diagnostic yield 30/969 3.1

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Secondary endpoints

• Sensitivity 91 (76-98)
• Specificity 88 (86-90)
• NPV 99 (99-100)
• PPV 21 (14-27)
• Specificity and PPV higher in post menopausal
  women

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Breast MRI

• Improves detection of contralateral breast cancer
• False positive rate of 10.9
• Low risk of detecting benign disease on biopsy
  9.4
• High cost of breast MRI
• ??? affects mortality ???