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Evolving Trends in Breast MRI


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Presentation on Evolving Trends in Breast MRI by Dr. Harriett B. Borofsky, Director of Breast Imaging, Mills-Peninsula Women's Center.

Presentation on Evolving Trends in Breast MRI by Dr. Harriett B. Borofsky, Director of Breast Imaging, Mills-Peninsula Women's Center.

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  • 1. Evolving Trends in Breast MRI Harriet B. Borofsky, M.D. Director of Breast Imaging Mills-Peninsula Women’s Center
  • 2. “ Conventional” Breast Imaging: 2011 and Beyond
    • Digital Mammography
    • Breast ultrasound
    • Breast MRI
  • 3. Mammography
    • Primary imaging modality in breast imaging and early detection/diagnosis of breast cancer
    • Only imaging modality proven to reduce mortality from breast cancer
      • Randomized Controlled Trials (RCT’s) 1963-1988; combined data suggest mortality reduction 29-40%
      • Felt to be an underestimate
  • 4. Digital Mammography
    • Major recent advance in mammography
    • Markedly improved contrast resolution
    • Studies have shown increase in breast cancer detection: in women with dense breasts, pre/perimenopausal and age < 50
    • Decreased mean glandular dose: 3.7 mGy vs 4.7 mGy
    • Increased efficiency of acquisition, storage and post processing of images
  • 5. Mammography – Limitations
    • Established false negative rate of 10-25%
      • Dense breasts/complex breast patterns
      • Overlapping structures
      • Heterogeneous histology of breast cancer; some occult
      • Interpretative “misses”
      • Not included on image
    • Underestimate extent of disease
      • Invasive lobular cancer; some invasive ductal cancers
      • DCIS
      • Incompletely includes the axilla
  • 6. Breast Ultrasound
    • Invaluable adjunct to mammography
    • Advances in high frequency, 14 MHz transducers with 3D format has led to improved resolution and increased utilization
    • Easy to perform and well tolerated
    • Safe: No radiation
    • Characterization of lesions, evaluation of clinical findings, guidance for biopsies, assessment of the axilla and screening high risk women with dense breasts
  • 7. Breast Ultrasound
    • Adjunctive screening in high-risk women with dense breasts
      • Kolb et al. Radiology 2002: Increased breast cancer rate by 13%
      • ACRIN 6666; JAMA, 2008: Increased breast cancer detection rate by 28%
    • In newly diagnosed breast cancer:
      • Can detect: additional ipsilateral disease in 14% and contralateral disease in 4%
      • Can assess axillary lymph nodes and guide biopsy
  • 8. Breast Ultrasound: Limitations
    • Time intensive
    • Operator dependent
    • Low sensitivity for DCIS
    • False positive rate
      • ACRIN 6666; JAMA, 2008: Adding US to mammography results in 4x as many false positives.
  • 9. Magnetic Resonance Imaging (MRI) of the Breast
    • Well established as imaging exam of choice in evaluation of silicone breast implants for rupture
    • Rapidly evolved into a highly valuable/clinically useful adjunctive imaging exam for breast cancer detection/diagnosis/preoperative planning
  • 10. MRI - Strengths
    • Morphologic and physiologic assessment with high sensitivity: most malignant lesions enhance following administration of contrast due to tumor neoangiogenesis
    • Cross-sectional; No overlap of structures
    • Ability to include the breast, chest wall and axillary region
  • 11. Strengths (cont.)
    • Uninfluenced by breast tissue density and complexity of fibroglandular pattern
    • Safe: no radiation
  • 12. MRI - Limitations
    • Low specificity: benign, malignant, atypical and proliferative changes enhance.
    • Variable and heterogeneous background enhancement of normal breast tissue, influenced by phase of menstrual cycle
    • Limited but growing clinical experience
    • No standard techniques: marked variability in quality of exams
    • Time intensive to perform and interpret
  • 13. Limitations
    • Contraindications: claustrophobia, pacemakers, some aneurysm clips, renal failure/GFR<50 due to NSF
    • Costly
  • 14. Recent Technical Advances Making MRI Feasible in Clinical Practice:
      • Dedicated tables and surface coils allowing rapid, high-resolution, dynamic imaging of both breasts at the same time
      • Robust fat suppression techniques
      • MRI-compatible power injectors
      • Dedicated computer soft ware programs for soft copy display, review and data analysis with 3D MIPS, angiogenesis maps and time intensity curves
      • MRI-guided biopsy techniques
  • 15. Sentinelle Table/Coil for Breast MRI
  • 16. Breast MRI: Literature Review
    • Sensitivity for invasive breast cancer: 86-100%
    • Sensitivity for DCIS: 40-100%
    • Specificity: 40-97%
    • False-negative rate for invasive cancer: 3-8%
      • Obscured by background enhancement
      • Tumor characteristics: small size, diffuse growth pattern, very well-differentiated and nonenhancing
      • Technical problems
  • 17. Breast MRI: Current Indications
    • Preoperative assessment of newly diagnosed breast cancers
    • Adjunctive screening in high-risk women
    • Identify occult tumor in women presenting with axillary metastases
    • Monitor response to neoadjuvant chemotherapy in women with advanced primary tumors
    • Screening women with silicone injections
    • Evaluation of silicone gel implants for rupture
  • 18.
    • MRI is not indicated for population-based screening
    • MRI is not indicated for the evaluation of mammographic or sonographic suspicious findings that otherwise should be biopsied
  • 19. 42 year old presenting with a large, palpable mass in the upper outer left breast: Pre and post neoadjuvant chemotherapy
  • 20.  
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  • 23. Silicone Injections
  • 24.  
  • 25. Breast MRI: Preoperative Assessment of Newly Diagnosed Breast Cancer
    • Most accurate assessment of tumor extent
    • Can detect occult additional ipsilateral disease in 6-34% of cases
    • Can detect occult contralateral disease in 4-24% of cases
    • May change surgical approach in 30% cases
            • Liberman et al. AJR 2003
            • Orel et al. Radiology, 1995
  • 26. Gutierrez et al. High Cancer Yield and Positive Predictive Value: Outcomes at a Center Routinely Using Preoperative Breast MRI for Staging. AJR, 2011
    • Retrospective review of 570 consecutive, newly diagnosed patients who underwent pre-operative MRI
    • Additional occult tumor detected in 12% : ipsilateral 8% , contralateral 4% .
    • PPV of biopsy: 44%
    • No significant differences in probability of detecting occult cancer based on age, breast density, index tumor or lymph node status.
  • 27. Houssami et al. Accuracy and Surgical Impact of MRI in Breast Cancer Staging. J Clin Oncol 2008
      • Meta-analysis of 19 published studies.
      • Breast MRI can detect additional disease in 16% of patients
      • Conversion from lumpectomy to mastectomy: 8.1%
      • Conversion to more extensive surgery: 11.3%
      • Lumpectomy to mastectomy based on MRI findings alone: 1.1%
  • 28. Ongoing Questions/Controversies
    • Does preoperative breast MRI impact overall survival, re-excision and recurrence rates?
    • Does preoperative lead to unnecessary mastectomies?
    • Does preoperative MRI lead to significant delay in treatment?
    • What about the added cost?
  • 29. Consider Preoperative MRI:
    • Uncertain tumor size and extent; especially with invasive lobular histology and DCIS
    • Patients at increased risk for mammographically/sonographically occult disease: dense/complex mammographic pattern
    • Young age and other risk factors
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  • 36. MRI-guided Breast Biopsy
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  • 44. Breast MRI – High-Risk Screening Setting
    • Six, prospective studies from The Netherlands, the United Kingdom, Canada, Germany, Italy and United States:
    • In specific high-risk women with genetic predisposition and/or family history, MRI can detect occult breast cancer in 2–8%
  • 45. American Cancer Society: Screening Breast MRI Recommendations; 2007
    • Annual breast MRI screening in conjunction with mammography in the following high risk women:
      • Known BRCA1/BRCA2 mutations
      • First degree relative of known BRCA mutations
      • Greater than 20% lifetime risk based on risk assessment models
      • Chest irradiation between ages 10-30
  • 46.
    • Insufficient data to recommend for or against adjunctive MRI screening in high risk women based on personal history of breast cancer and/or atypical ductal hyperplasia or lobular neoplasia.
  • 47. Brennan et al. Breast MRI Screening of Women with A Personal History of Breast Cancer. AJR 2010.
    • Retrospective review of 144 women with personal history of breast cancer and no family history; 17 cancers diagnosed
    • 10 cancers detected at MRI alone
    • MRI increased breast cancer detection rate by 12%
    • PPV of 39%
  • 48.  
  • 49. Future Advances in Breast MRI
    • Breast MRI at 3T. Optimal breast imaging has not as yet been achieved or reported
    • Breast MR Spectroscopy: dedicated coils and pulse sequences to determine choline and sodium levels which may be associated with malignancy.
  • 50. Summary
    • Mammography remains the primary imaging modality in screening and diagnostic breast imaging
    • Ultrasound invaluable and complimentary to mammography for lesion and clinical finding evaluation, guidance for biopsies, select screening
    • Breast MRI plays important and increasing role in select settings: high-risk screening, preoperative assessment and occult malignancy detection
  • 51.