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.

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Evolving Trends in Breast MRI

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