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Breast imaging birads irm t pousse

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Breast imaging birads irm t pousse

  1. 1. Breast MRI:Updates to BI-RADS Lexicon T Pousse JFIM 2013 HONG KONG
  2. 2. Aims •  Recall and illustrate new synthetic items of BI-RADS MRI •  Insist on changes to the BI-RADS MRI lexicon in this third edition
  3. 3. Technical parameters •  Dedicated breast coil, pulse sequence, (T2/T2 fat sat), IVC •  Diffusion weighted or spectroscopy optional •  T2 weigthed recommanded before IVC
  4. 4. Background Parenchymal Enhancement ( BPE) •  5 categories - none - minimal - mild - moderate - marked
  5. 5. minimal moderate mild marked
  6. 6. Influence of Background Parenchymal Enhancement •  Greater BPE may negatively influence breast MRI performances (DeMartini, AJR 2012 536 patients versus 200 patients) –  Decreasing specificity : increase of abnormal exam (30% vs 23%) –  No significant difference in positive rate of biopsy, cancer yield •  In the analysis of breast cancers not diagnosed at MRI : less misdiagnosis of detection than caraterisation Mistakes detection not influenced by BPE (Bouic-Pages Radiology 2012) •  BPE influenced by hormonal fluctuation ,HRT, or Tamoxifen
  7. 7. Lesions characteristics •  Morphology –  Masses –  Non-masse enhancement –  Foci (≤ 5mm) •  Enhancements Kinetics
  8. 8. Masses •  Space occupying 3D lesions > 5 mm - shape ( 2D ) - margin - internal rehaussement characteristics - T1-T2 weighted pulses sequences pre/ post contrast
  9. 9. Masse shape SHAPE Rond Oval (replace macrolobulated) Irrégular macrolobulated
  10. 10. Mass margins Margins Régular Irregular circumscribed replaced smooth Irrégular : combined shape+margins Spiculated
  11. 11. Mass internal enhancement patterns Homogeneous Heterogeneous Central enhancement Enhancing internal septation Rim enhancement Dark internal septa
  12. 12. Rim Enhancement value •  Bénign –  Inflammatory cyst –  Cytosteatonecrosis •  Malignant –  Triple negative Cancer
  13. 13. RIM ENHANCEMENT K Triple négative
  14. 14. T2- weighted signal intensity on non-contrast images : new mass feature in the revised lexicon! •  Hypersignal T2 ? –  T2 : •  > Parenchyma •  ≥ FAT –  T2 fat sat: •  > Parenchyma •  ≥ WATER , VESSEL
  15. 15. T2 Hypersignal : mechanism Bénign •  Cystic and microcystic comp. •  Altered fat •  Fibroadenoma, intrammary lymph node, phyllodes tumor Malignant •  Tumor necrosis •  Mucinous subtype cancer
  16. 16. Family juvenile papillomatosis
  17. 17. Mucinous cancer
  18. 18. CCI grade 3
  19. 19. Non-Mass Enhancement Enhancing area that is not a mass , separate from background parenchymal enhancement may contain interspersed fat –  Distribution (symetric or asymetric) –  Internal enhancement characteristics –  T2 weighted signal intensity
  20. 20. Fat area or normal parenchyma inside enhancement
  21. 21. NME distribution •  •  •  •  •  •  •  Focal area ( <25% Q) Linear Branching linear : replace ductal Segmental Regional Multiple regions >2 Diffuse •  Symetric or not
  22. 22. Focal zone Often mixed with fat or normal matrix <25% Q
  23. 23. Distribution : linear enhancement
  24. 24. Distribution : linear enhancement DUCTAL
  25. 25. Benign NME linear enhancement
  26. 26. Linear branching
  27. 27. Segmental
  28. 28. Symetric or asymetric Diffuse bilateral symetric enhancement
  29. 29. Symetric or asymetric •  Asymetric Regional, bilateral and asymetric enhancement
  30. 30. NME internal enhancement •  •  •  •  •  Homogeneous Heterogeneous Stippled ( multiple punctuate foci : benign BPE) Clumped (cobblestone ,beaded enhancement ) Clustered ring enhancement Reticular /dendritic Clustered ring (ductal carcinoma in situ) Stippled :BPE
  31. 31. Ring enhancement
  32. 32. Ring Enhancement PPV of malignancy = 70-100% Ductal carcinoma invasive cancer associated with ductal carcinoma in situ Uematsu AJR 2012 Non masse 3T Tozaki AJR 2006
  33. 33. T2 Signal
  34. 34. Kinetic curve assessment S0 St0" S1 3 Rapid (intense)" Medium" Persistent " 2 St1" S S2 t2" Persistent Plateau Wash out 1 ROI > 3 pixels More suspicious area t0= 0 t1= 2.5 IV contrast" t2= 7.5 Time (min)
  35. 35. Kinetic enhancement 2 3 2 Persistent Plateau 1 ROI > 3 pixels More suspicious area Wash out Temps (min)
  36. 36. Kinetic curve assessment •  Initial Phase (2 mns) (intensity + speed) - slow : < 50% - medium : 50-100% - rapid : > 100% •  Delayed Phase - persistent - plateau - Wash out Qualitative appreciation No quantitative cut – off Menopausis status impact / kinetic curve enhancement (Milllet Radiology 2013)
  37. 37. Associated findings •  •  •  •  •  •  •  Nipple or skin retraction Skin thickening ( focal or diffuse) Edema Lymphadenopathy Pectoralis muscle involvement Precontrast increased ductal signal intensity Susceptibility artifact related to surgical clips
  38. 38. Implants •  Material type : silicone, saline •  Location: retro-glandular or retropectoral •  Intra or extra-capsular rupture
  39. 39. Using new lexicon •  PPV for malignancy:mass –  Irregular shape and margin –  Spiculated –  Ring sign –  Heterogeneous –  Wash out kinetics •  PPV for malignancy : non mass –  Distribution : linear branching and segmental –  Internal enhancement : clumped and clustered ring
  40. 40. Breast MRI interpretation •  BI-RADS IRM –  0 : if suspicion of benign lesion (ex : FA) –  4 : biopsy recommended ( even if US performed for choice of the guidance) –  3 (PPV variable in MRI) •  Global BI-RADS : combined reporting with mammography / US
  41. 41. Conclusion •  T2 weighted sequence •  Background parenchymal enhancement •  Masses / non masses enhancement : simplification •  Breast implant •  Management / facilitation patient care : BIRADS 0, 4, 3 •  BIRADS global
  42. 42. Thanck you Patrice

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