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Breast imaging pitffals mri p taourel

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Breast imaging pitffals mri p taourel

  1. 1. Pitfalls in breast MRI : How to deal between Sensitivity and Specifcity ? P. Taourel, E. Pages
  2. 2. Breast MRI : a weak specificity •  Studies comparing MRI and MG –  Staging of brast cancer : Spe = 70% close to Spe of MG –  High risk women : Spe = 90 % •  Why this feeling of low specificity –  enhancement ≠ cancer –  Lack of experience –  Difficulty of biopsy C Kuhl Radiology 2007
  3. 3. Breast MRI : is it perfectly sensitive ? •  The sensitivity of an exam depends of the gold standard > 95 % in most of the studies ≈ 75 % in screening studies = 85 % in the stidy with gold standard = pathologic analysis of mastectomy •  MRI Sensitivity > Sensitivity of other imaging modalities
  4. 4. Causes of avoidable F+ •  Artefacts •  Normal structures •  Benign tumors
  5. 5. Causes of avoidable F+ •  Artefacts •  Normal structures •  Benign tumors
  6. 6. Backround enhancement •  Bilateral and symmetric •  Hormonal and therapeutic context •  Age of the patient •  The backround enhancement must be graded
  7. 7. Genetic risks, BRCA 1 40 years old
  8. 8. Genetic risks 40 years old Right mass : fibroadenoma ovariectomy
  9. 9. To analyze / classification BIRADS •  Mass –  3D –  Cancer, FA, papilloma, fat necrosis, sclerosing adenosis, lymph node, some atypical form of benign lesions –  Key features for Benign: •  •  •  •  •  •  Smooth outline Regular form Homogeneous enhancement (value if big) Hyper T2 Fat content Weak enhancement and no wash-out
  10. 10. 2009 2010
  11. 11. Value of hyper T2 if homogeneous
  12. 12. Rim must be analyzed according to the content and the regular pattern
  13. 13. To analyze / BIRADS classification •  Non mass enhancement –  Neither mass nor focus –  Benign mass, young patient, inflammation, DCIS, ILC –  Key features for enhancement : •  Bilateral and symmetric •  Cysts ++ •  Negative findings
  14. 14. To analyze / classification BIRADS •  Focus –  < 5 mm –  Very low rate of malignancy –  Key features for benign (no F.U = BIRADS 2) •  Multiple •  No wash-out •  Clinical context
  15. 15. F•  Lack of enhancement •  Not seen –  Backround enhancement, artefact –  small –  Tricky area •  Misinterpretation •  Mismanagement
  16. 16. Causes of False negative •  Retrospective review of 60 pairs of breast cancer •  47% of « errors » –  10% = misdiagnosis –  25% = misinterpretation –  12% = mismanagement Pages Radiology 2012
  17. 17. Lack of enhancement •  DCIS •  Small invasive cancer •  Some pathologic pattern: –  Inflammatory cancer –  Invasive lobular carcinoma
  18. 18. F•  Lack of enhancement •  Not seen –  Backround enhancement, artefact –  small –  Tricky area •  Misinterpretation •  Mismanagement
  19. 19. Oct 2004 Mai 2005
  20. 20. 1an plus tard
  21. 21. F•  Lack of enhancement •  Not seen –  Backround enhancement, artefact –  small –  Tricky area •  Misinterpretation •  Mismanagement
  22. 22. 2007   2008   Benign morphology’’ : oval form, smooth outlines, non enhanced septas
  23. 23. Forme ronde Phénotype triple-négatif RP- RE- HER2 -
  24. 24. Benign/malignant association
  25. 25. 1 year later
  26. 26. 2003 2005 2006
  27. 27. Be careful with kinetic, particularly in menopausal patients 2 3 OR not to have malignant curve in menopausal 2 patients : 2.94 : initial rise 2.38 : washout 1 I Millet Radiology dec 2013 Progressive Plateau ROI > 3 pixels Région la plus suspecte Lavage Temps (min)
  28. 28. F•  Lack of enhancement •  Not seen –  Backround enhancement, artefact –  small –  Tricky area •  Misinterpretation •  Mismanagement
  29. 29. • Retrocystic enhancement
  30. 30. Importance du clip
  31. 31. How to avoid F+ and F- ? 1.  2.  3.  4.  To recognize the pseudo-enhancement To negative normal structure : bilateral foci, punctuate enhancement, lymph nodes 6 month FU Interpretation according to clinical context and personal status - focus/BIRADS - enhancement/menopausal status 5.  6.  Be careful with stability (morphology +++) Be careful with autosatisfaction : FU of benign results in biopsy performed on 2d look US

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