Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Breast imaging breast mri s taieb

1,646 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Breast imaging breast mri s taieb

  1. 1. New Breast MR Imaging Sophie Taïeb, Luc Ceugnart Anticancer center Oscar Lambret - Lille -
  2. 2. Ø  Perform in specialist breast units with experience in CI ü At least 150 MRI / year / centre ü MRI biopsy in house or agreement with another institution Ø  Use adequat sequences in adequat period of menstrual cycle (7-12) Ø  Respect indications Ø  Use Birads lexicon to describe lesions
  3. 3. 35 y-o. BRCa2. Yearly MRI Right Breast : Mass BiRads 5 •  US: mass 25 mm •  IDC grade 3 •  RE+, RP-, Her2 -, Ki67 25-30%
  4. 4. Right breast 6h : DCIS •  Pas de traduction echo- mammographique
  5. 5. Right mastectomy Ø IDC 16 mm Ø DCIS 11 mm Ø 1N+ / 13 N MRI allows to highlight carcinoma not seen on mammo or US J
  6. 6. 41 y-o - Nurse Normal physical examination Mother with breast carcinoma under 50 years-old 1st mammography
  7. 7. US : no lesions seen BiRads 3 or MRI ?
  8. 8. BiRads 2
  9. 9. MRI = PROBLEM SOLVING J
  10. 10. CONTRALATERAL BREAST 3rd sequence postC T2FS Washin card Ø  BiRads 3 Ø  US : not seen
  11. 11. Follow up 4 months : Persistence of lesion Biopsy Failure
  12. 12. 2 Months later : SURGERY MRI wire localization Ø HYPERPLASIA without atypical cells MRI = Problem creating L
  13. 13. The breast MRI we need Ø  Safe : No toxicity (gadolinium-chelates) Ø  High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease Ø  Good reproducibility : Inter et Intra observers Ø  Low coast : Money, Medical’s and Patient’s time Ø  Easy comparison with gold standards ü  Mammo – US ü  Biopsy - Surgery ü  Histopathology
  14. 14. The breast MRI we need Ø  Safe : No toxicity (gadolinium-chelates) Ø  High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease Ø  Good reproducibility : Inter et Intra observers Ø  Low coast : Money, Medical’s and Patient’s time Ø  Easy comparison with gold standards ü  Mammo – US ü  Biopsy - Surgery ü  Histopathology
  15. 15. MRI = Poor specificity Ø  44 studies / 251 : 1985 - 2005 Ø  Se : 90% [0.88-0.92] Ø  Sp : 72% [0.67-0.77]
  16. 16. Ø  11 studies (1994-2007) – No randomised studies Ø  2 mutations (727), 9 mutations + risk > 15% for all life (4939) Ø  218 cancers : 3.5% (45) - 2% (171) - 20% DCIS - 60%N+ (126) Ø  Se : Mammo 14-59% ; MRI 51-100% Ø  Sp : Mammo 91-100% ; MRI 79-98%
  17. 17. Ø  50 / 237 – 1996-2011 Ø  10811 women Ø  Extension surgery in 12,8% but useless in 6,3% of cases Ø  Miss information about overall survival Ø  MRI : ü  20% homolat lesions. PPV of cancer : 59-74% à need biopsy PPV : 75% if > 1,5T ; 59% if < 1,5T ü  5,5% controlat. PPV of cancer : 27-47% à need biopsy PPV : 40% if > 1,5T ; 19% if < 1,5T
  18. 18. Improve specificity : 3T MRI ? Ø  Adequat sequences : 2nd Week of menstrual cycle ü  At least one unenhanced high-contrast sequence (T2 FSE) ü  2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness < 4mm, < 120 sec. ü  Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)
  19. 19. Improve specificity : 3T MRI ? Ø  Adequat sequences : 2nd Week of menstrual cycle ü  At least one unenhanced high-contrast sequence (T2 FSE) ü  2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness < 4mm, < 120 sec. ü  Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml) Ø  Centre Oscar Lambret - 3T : 3D Vibrant (GE) ü  5 x 80 secondes ü  Pixel 0,66 mm2, Thickness 2,2mm, No Gap. ü  S1 – begining injection 20sec. before the end, 4 post injection
  20. 20. Improve specificity : 3T MRI ? Ø  Adequat sequences : 2nd Week of menstrual cycle ü  At least one unenhanced high-contrast sequence (T2 FSE) ü  2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness < 4mm, < 120 sec. ü  Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml) Ø  Centre Oscar Lambret - 3T : 3D Vibrant (GE) ü  5 x 80 secondes ü  Pixel 0,66 mm2, Thickness 2,2mm, No Gap. ü  S1 – begining injection 20sec. before the end, 4 post injection Ø  No studies demonstrate 3T > 1,5T ü  Best spatiale resolution ü  Best temporal resolution : 15 - 20 mn T1 + T2 + DWI-w + 3D dynamic + Late Sequence (DCIS)
  21. 21. Improve specificity : DWI-MRI ? Ø  à 2009 : 13 / 65 études Ø  615 Cancers, 349 LB Ø  b 1000 -Se : 0.84 [0.8-0.87]; Sp 0.84 [0.79-0.88]
  22. 22. ü  93 women, 101 lesions. 3T, b0, b600. ü  33 BL : 9 FA, 3 intraductal Papillomas, 4 Fibrocystic L, 4 sclerosing aden. 2 ADHL, 11 areas of benign breast tissue ü  68 K : 23 IDC, 26 IDC+DCIS, 9 DCIS, 6 ILC, 4 others
  23. 23. •  27  y-­‐o.  Pregnant  :  8  Weeks     •  Le6  B  :  IDC  Grade  3  RE-­‐,  RP-­‐,  Her2  -­‐.  
  24. 24. •  27  y-­‐o.  Pregnant  :  8  Weeks     •  Le6  B  :  IDC  Grade  3  RE-­‐,  RP-­‐,  Her2  –   •  Right  B  :  ?   S3 Diffusion b 1000 Native 3 ADC
  25. 25. •  27  y-­‐o.  Pregnant  :  8  Weeks     •  LB  :  IDC  Grade  3  RE-­‐,  RP-­‐,  Her2  –   •  RB  :  ?   ADC: 2, ADC: 0,86.10-3 ADC: 1,26.10- 3
  26. 26. •  27  y-­‐o.  Pregnant  :  8  Weeks     •  LB  :  IDC  Grade  3  RE-­‐,  RP-­‐,  Her2  –   •  RB  :  ?   ADENOSIS ADC: 2, ADC: 0,86.10-3 ADC: 1,26.10- 3
  27. 27. 54  y-­‐o.  MulKfocalité  on   mammography  ?   RB  :  2nd  lesion  :  Birads  5  
  28. 28. 54  y-­‐o.  MulKfocalité  on   mammography  ?   RB  :  2nd  lesion  :  Birads  5  
  29. 29. 54  y-­‐o.  MulKfocalité  on   mammography  ?   RB  :  2nd  lesion  :  Birads  5  
  30. 30. 54  y-­‐o.  MulKfocalité  on   mammography  ?   LB  :  
  31. 31. 54  y-­‐o.  MulKfocalité  on   mammography  ?   LB  :  Lymph  node  
  32. 32. Artefacts fréquents…. Courtesy Dr C.Balleyguier
  33. 33. Improve specificity : Contrast media ? Support: Bracco Ø  Centers 17 : 07/2007 – 05/2009 Ø  162 Mammo ou US : Birads 3, 4, 5 (biopsy needed) Ø  82 Gadobenate Dimeglumine / 80 Gadopentate Dimeglumine Ø  2nd MRI > 2 days; < 7 days Ø  136 patients with both. GB : 7 atopic reactions, GP : 6 Ø  Independant 2nd reading : 3 readers + 4th review reader
  34. 34. Ø  136 double examinations : 216 lesions Ø  144 cancers : ü  87 IDC, 30 ILC, 5 both, 5 others ü  13 DCIS, 3 LN, 1 mixte Ø  52 Benign lesions Ø  20 Birads3 : follow-up Results : 3 readers Ø  Cancer detection rate : GB 91.7, 93, 94.4% > GP 79.9, 80.6, 83.3% Ø  Se : GB 91.1, 94.5, 95.2% > GP 81.2, 82.6, 84.6% Ø  Sp : GB 99, 98.2, 96.9% > GP 97.8, 96.9, 93.8%
  35. 35. 50 y-o, DCIS
  36. 36. Use Birads to describe lesions Objective : BiRads : 0? 1? 2? 3? 4? or 5? 1.  Density : 1 to 4 ≈ Mammography 2.  Background Parenchymal enhancement
  37. 37. Use Birads to describe lesions Objective : BiRads : 0, 1, 2, 3, 4 ou 5 ? 1.  Density : 1 to 4 ≈ Mammography 2.  Background Parenchymal enhancement 3.  Lesion analysis – morphology ü  Detection : 1st post contrast sequence (soust – MIP) ü  Analysis : 2nd post contrast sequence (native – MIP)
  38. 38. 3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement Conclusion:BiRads 0? 2? 3? 4? 5 ?
  39. 39. 3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement Conclusion:BiRads 0? 2? 3? 4? 5 ?
  40. 40. Focus
  41. 41. 3T, GB BiRads : 0, 2, 3, 4, 5 ?
  42. 42. 45 y-o, 29 y-o, 3T, GB BiRads : 0, 2, 3, 4, 5 ? 54 y-o.
  43. 43. 3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement Conclusion:BiRads 0? 2? 3? 4? 5 ? BiRads Mammo & US : According to images alone BiRads MRI : According to MR images and CI and 2nd look US and context (and intuition?)
  44. 44. 45 y-o, BRCA2 2-2011 29 y-o, BRCA2 – 1st IRM – 1/2010 BiRads : 0, 2, 3, 4, 5 ? 54 y-o. IDC bi-focal
  45. 45. 45 y-o, BRCA2, CI normal 2009 2-2011 BiRads 3
  46. 46. 45 y-o, BRCA2 CI normal 2009 2-2011 BiRads 3 6-2011 1-2013 Birads 2
  47. 47. 29 y-o, BRCA2 – 1st IRM – 1/2010 2nd look Mammo & US normal Birads3 D Birads3 G
  48. 48. 29 y-o, BRCA2 – 1st IRM – 1/2010 4/2010
  49. 49. 29 y-o, BRCA2 – 1st IRM – 1/2010 4/2010 : IDC, G3, ER+, PR-, Her2-, N-
  50. 50. §  54 y-o, Left breast : IDC 8 mm – BiRads6- IDC BiRads 6 - IDC
  51. 51. 54 y-o Left breast : IDC 4,1mm
  52. 52. §  54 y-o, Left breast : IDC Retraction + lesions Birads 6 4,1mm FOCUS Birads 4 : IDC
  53. 53. Kinetic curves Ø  After morphological analysis (Kuhl, AJR 2005)
  54. 54. Kinetic curves Ø  After morphological analysis (Kuhl, 2005) Type 3 Ø  (Kuhl, 1999) 57% in carcinoma 5% in benign Lesion
  55. 55. Kinetic curves Ø  After morphological analysis (Kuhl, 2005) Type 1 Type 2 34 % : K 12% : BL 9% : K 83% : BL
  56. 56. Foci or UBO (unidentify bright object) Ø  Birads2 if : ü  ü  ü  ü  < 5 mm, No associated findings Not menopausal women, not after radiation therapy Easier if multiple and bilateral : Background enhancement
  57. 57. Foci or UBO (unidentify bright object) Ø  Birads2 if : ü  ü  ü  ü  < 5 mm, No associated findings Not menopausal women, not after radiation therapy Easier if multiple and bilateral : Background enhancement Ø  Birads3 if ü  1st MRI in BRACx women ü  Post menopausal or post radiation therapy ü  Unique or few or in not glandular zone of breast. ü  Breast cancer or Birads 5 Lesion in contralateral breast Follow up : 3/4 months, 6/8 months, 12 months
  58. 58. Foci or UBO (unidentify bright object) Ø  Birads2 if : ü  < 5 mm, ü  No associated findings ü  Not menopausal women, not after radiation therapy ü  Easier if multiple and bilateral : Background enhancement Ø  Birads3 if ü  1st MRI in BRACx women ü  Post menopausal or post radiation therapy ü  Unique or few or in not glandular zone of breast. ü  Breast cancer or Birads 5 Lesion in contralateral breast Follow up : 3/4 months, 6/8 months, 12 months Ø  Birads 4 Lesion Birads 5 or 6 in same breast = biopsy PPV of cancer : 3 à 95% If < 4mm : PPV of biopsy : 0 ; If > 4 mm : PPV of biopsy 20-30%
  59. 59. 3 lesion types : Ø Foci Ø Masses : MARGIN Ø Non-Mass Enhancement Conclusion:BiRads 0? 2? 3? 4? 5 ?
  60. 60. RNM
  61. 61. NME Ø  2003-2005 : 1523 MRI / 1128 p Ø  258 L BiRads 4,5 – 196 p : 186 LB, 72 Cancers (21 DCIS, 34 DIC 11 LIC, 6 others) Ø  95 NME ü  27 M ü  68 B
  62. 62. NME Ø  2008-2009 : 131 NME / 115 p – Breast cancer 46, HR 29, PS 40 Ø  63 BL, 12 FL, 56 Cancers
  63. 63. NME symmetric, focal, bilateral : BiRads 2
  64. 64. NME, asymmetric : not so easy
  65. 65. NME, asymmetric : not so easy Radiation therapy of the Left B 5 years ago … BiRads2
  66. 66. 49 y-o, BRCA2, first MRI ACR4 : DCIS
  67. 67. NME
  68. 68. 2mn T2 6mn T1
  69. 69. 4/5
  70. 70. 4/5 4/5
  71. 71. 4/5 4/5 3
  72. 72. 4/5 131 L 31 Birads 3 : 1 C 100 BiRads 4/5 : 56 C ou FL 4/5 FP : 74/131 (55%) 4/5 4/5
  73. 73. 2nd look US - Biopsies Ø  Visibility : Masses 57- 62%, NME 12-31 %
  74. 74. 2nd look US - Biopsies Ø  Visibility : Masses 57- 62%, NME 12-31 % Ø  PPV of K if lesions seen on 2nd look US or not ü  Demartini, 2009 : (167) 36% - 22% ü  Abe, 2010 : (202) 29% - 13% If MRI + and US - : 13 à 35% K à Biopsy always ++
  75. 75. 2nd look US - Biopsies Ø  Visibility : Masses 57- 62%, NME 12-31 % Ø  PPV of K if lesions seen on 2nd look US or not ü  Demartini, 2009 : (167) 36% - 22% ü  Abe, 2010 : (202) 29% - 13% If MRI + and US - : 13 à 35% K à Biopsy always ++ Ø  Meissniger, 2009 : Corrélation MRI / US : 519 ü  56% ok : 62% if masses – 31% if NME ü  80 US Biopsy for BL 10 lesions not same on MRI and US : 9 cancers Thomassin et al. Breast Cancer Res Treat. 2012 A plea for the biopsy marker: how, why and why not clipping after breast biopsy?
  76. 76. The breast MRI we need Ø  Safe : No toxicity (gadolinium-chelates) Ø  High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease Ø  Good reproducibility : Inter et Intra observers Ø  Low coast : Money, Medical’s and Patient’s time Ø  Easy comparison with gold standards ü  Biopsy ü  Surgery ü  Histopathology
  77. 77. The breast MRI we dream Ø  No contra indications Ø  Suppine position likes US, Surgery and radiotherapy Ø  No contrast need Ø  Few sequences to characterize (without doubts) ü  Lesions ü  Treatment response Ø  Uncertainties of radiological analysis easy to explain to referent collegues and patients … (with color and arrows to help them to find target – may be a need for radiologist also)
  78. 78. SUPPINE POSITION ü  ECR 2013 : B- 0325 = Meilleure délimitation pour le boost de radiothérapie
  79. 79. SUPPINE POSITION Nakano et al. Breast Cancer Research and Treatment 2012 ü  196 patients MRI in suppine position. 67 lesions in 55p. ü  24M, 43B ü  2nd look sonogrphy : real-time virtual sonography Real-time US Pre-contrast T1WI Early phase T1WI Late phase T1WI
  80. 80. ECR 2013 : No contrast ü  B- 0453 = FSET2 ideal + Diff (3T, 31 cas) No contrast needed for response assessment after neoadjuvant Chemotherapy ü  B- 0954 = Multi spectral sequences with T1 and T2 cartography §  46 lesions (18 B, 28 M) §  Ratio T1/T2 élevé dans K
  81. 81. Key points 1.  2.  3.  4.  Respect indications Respect technical conditions Use BiRads lexicon (allowed Birads 0) 3T, Contrast-media, DWI-MRI helpfull No more problems after MRI than before ü  Explain it to referent collegues ü  Explain it to patients Before to perform Breast MRI
  82. 82. Thank you

×