Mr Mammography New

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Mr Mammography New

  1. 1. Current & Potential Utility of MRI in Diagnosis & Management of Breast Cancer By: Dr. Norran Hussein, MS Cairo University
  2. 2. Why MRI of the Breast? <ul><li>Imaging of the breast for cancer detection aims to fulfill two major goals: </li></ul><ul><li>-high sensitivity for detection of breast lesions </li></ul><ul><li>-and reliable differentiation of benign from malignant lesions (specificity). </li></ul><ul><li>In the results of several large MRM studies, sensitivities of 83%-96% for detection of breast carcinomas were reported. However the specificity remains variable ranging from 37% to 89%. </li></ul>
  3. 3. Indications Post operative Breast Dense Breast at high Risk Evaluation of Prosthesis <ul><li>6m of surgery </li></ul><ul><li>6m silicone implants </li></ul><ul><li>10m RT </li></ul>Pre operative staging Positive family history Search for 1ry Follow up after chemotherapy
  4. 4. A basic MRM 1) Dynamic 2) Subtraction 3) Curve pre 1 min 2 min 3 min 4 min 5 min
  5. 5. A basic MRM 1) Dynamic 2) Subtraction 3) Curve 1 minute subtraction pre 1 min
  6. 6. MRI BIRADS Lexicon Is it a : Mass Focus Non mass like Enhancement Other findings? Kinetic Curve analysis Shape Margin Distribution Symmetrical/ Assymetrical BIRADS Category Enhancement Pattern
  7. 7. Post operative/ Radiated Breast
  8. 8. Post Operative& Radiated 58 year old woman who underwent left lumpectomy for Ca Breast 2 years before, followed by sessions of Radio & chemotherapy which were completed 3 months later. Bilateral MLO Mammography Ultrasonography of the scar L R
  9. 9. Case 6 Axial Subtraction Saggital T2 Axial T1 Axial T2 IR MIP
  10. 10. Axial Dynamic post contrast Fat suppressed FLASH, with signal-time analysis curve Pathology: Recurrent Invasive Duct Carcinoma
  11. 11. Dense Breast
  12. 12. Malignant LN searching for a 1ry
  13. 14. Pre operative evaluation 47 year old patient presenting with Left breast lump.
  14. 15. T2 IR Subtraction T1/ Gd
  15. 16. Case 3 Diagnosis: Lt UOQ Invasive Duct Carcinoma
  16. 17. Pre operative A 43 year old woman presenting with a left breast lump
  17. 18. Pre operative
  18. 19. Follow up chemotherapy Pre treat. Post treat.
  19. 20. MRI of Implant Failure
  20. 21. Fibrous capsule Fibrous capsule Radial folds Radial folds Normal Implants
  21. 22. MRI of Implant Failure Suspicious Findings: Loss of Round or Oval form Contour Bulge
  22. 23. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Capsular contracture occurs when the AP diameter of the implant is nearly equal to the TS diameter. (normally AP:TS ratio is 1:2)
  23. 24. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Axial T2 Fat Sat shows collapsed shell with residual saline The saline is usually absorbed, and linguine sign is not visible in saline implants
  24. 25. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Saline outside fibrous capsule
  25. 26. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Inverted tear drop C sign
  26. 27. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Key hole sign
  27. 28. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Linguine Sign
  28. 29. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture In double lumen implants, if the inner shell ruptures, a mixture between the saline and silicone occurs: The salad oil phenomenon.
  29. 30. <ul><li>There is an overlap between benign and malignant lesions in the pattern of contrast uptake. </li></ul><ul><li>DW MRI provides information about the state of molecular translational motion of water. </li></ul><ul><li>As the cellularity of malignant breast tumours is known from histological examinations to be hypercellular compared to benign, these differences should be reflected in DWI. </li></ul><ul><li>The mean value of the Apparent Diffusion Coefficient (ADC) of the malignant tumours is reduced compared to that of the benign lesions and normal tissues (due to their increased cellularity). </li></ul>MR Diffusion
  30. 31. MR Diffusion ADC maps in a patient with a malignant breast Tumour. Images are shown in 8 spatial locations with the tumour seen as a hypointense area on the last 2 images.
  31. 32. Hyperintense region of in the ADC map representing a cyst. MRI T2WI ADC Map
  32. 33. ADC maps in a patient with a malignant breast lesion. Images of 8 spatial locations show the decreased ADC values of the tumour. Other hypointense areas were attributed to fat.
  33. 34. Normal MRS of the Breast 7 6 5 4 3 2 1 0 -1 Frequency (ppm) Fat Choline Water Un Sat FA Un Sat FA
  34. 35. Normal MRS of the Breast 7 6 5 4 3 2 1 0 -1 Frequency (ppm) Water <ul><li>Located at 4.77 ppm </li></ul>
  35. 36. Normal MRS of the Breast 7 6 5 4 3 2 1 0 -1 Frequency (ppm) Un Sat FA Un Sat FA <ul><li>Their peak is located at </li></ul><ul><li>1.97 to 2.77 ppm </li></ul><ul><li>5.3 ppm </li></ul>
  36. 37. Normal MRS of the Breast 7 6 5 4 3 2 1 0 -1 Frequency (ppm) Fat <ul><li>Their peak is located at 1.4 ppm </li></ul><ul><li>Water to fat ratios: </li></ul><ul><li>The ratio of water/ fat, and water to unsaturated fatty acids was found to vary between healthy women and women with breast cancer. </li></ul>
  37. 38. Normal MRS of the Breast 7 6 5 4 3 2 1 0 -1 Frequency (ppm) Choline <ul><li>The Cho peak is located at 3.2 ppm and contains contributions from glycerophosphocholine, phosphocholine, and free Cho. </li></ul><ul><li>The molecules are located in the cell membranes and reflect the phospholipid membrane turnover, and the peak is elevated in neoplastic diseases. </li></ul><ul><li>It is caused by rapid cell membrane turnover, and increased cellular density </li></ul>
  38. 39. However….. Lesion size Magnet strength Lactating breast < 2.5 2.5 – 4.9 > 5.0 (cm 3 ) Probability (%) The Probability to Detect Choline in Breast Cancer is Higher in the Larger Lesions
  39. 40. How to analyse a spectrum Step 1: Quality assurance (is this an adequate spectrum) <ul><li>Make sure there is good water and Fat suppression. </li></ul><ul><li>Stay away from hgic, cystic areas. </li></ul><ul><li>Make sure your voxel does not contain fat. </li></ul>
  40. 41. How to analyse a spectrum Step 1: Quality assurance (is this an adequate spectrum) Step 2: check quantities of metabolites <ul><li>choline: present or absent </li></ul><ul><li>Water to lipid ratio </li></ul>-Peak at 3.2ppm -SNR >2 -At least 2 of 3 spectra acquired at different TE values.
  41. 43. 1 H-MRS of Breast Carcinoma H 2 O Fat Cho Cho
  42. 45. Mastopathy in a 48-year-old woman
  43. 46. Response to chemotherapy A promising application is the use of breast MRS for predicting response to cancer treatment. Current clinically available methods such as palpation and imaging rely on changes in tumor size, which take several weeks before any changes are detectable. Breast MRS, in contrast, reflects changes in intracellular metabolism that would occur before any gross morphological change.
  44. 47. Response to chemotherapy In the results of a study presented in RSNA 2003 meeting: 12 women with biopsy proven Ca, were examined with MRS before and within 24hrs of chemotherapy. Patients which showed decreased choline within 24hrs showed a tumour reduction size, after 12 wks of ttt. Patients with cte or elevated choline within 24hrs, failed to have anatomic response to therapy.
  45. 48. Axilla
  46. 49. Addition of MRS to MRI improved specificity from 62.5% to 87.5% (Huang et al,2004)
  47. 50. Conclusion <ul><li>Metastatic axillary nodes </li></ul><ul><li>improving the diagnostic sensitivity and specificity and hence reducing the un-necessary intervention. </li></ul><ul><li>to monitor response to neoadjuvant therapy . </li></ul><ul><li>A potential application of in vivo 1H MR spectroscopy may be the noninvasive evaluation of the sentinel node for prognostic and surgical planning purposes. </li></ul>
  48. 51. Conclusion: Limitations <ul><li>Ductal carcinoma in situ. </li></ul><ul><li>Small lesions. </li></ul><ul><li>Breast-feeding women </li></ul>
  49. 52. Conclusion
  50. 53. <ul><li>Technique: </li></ul><ul><li>Freehand or Stereotactic </li></ul><ul><li>Needles and wires should be MR compatible </li></ul>Biopsy: Mr Guided <ul><li>Freehand: </li></ul><ul><li>MRI done in supine position before and after iv CM </li></ul><ul><li>2skin markers: </li></ul><ul><li>tube filled with diluted Gd-DTPA & </li></ul><ul><li>vit E capsule (reference TS slice) </li></ul><ul><li>Based on these 2 markers and the position of the lesion, an exact entrance and needle path can be planned. </li></ul><ul><li>Stereotactic </li></ul><ul><li>Devices must allow </li></ul><ul><li>1. sufficient fixation of the breast </li></ul><ul><li>2. accurate stereotactic system to allow pinpoint accuracy of the needle </li></ul><ul><li>3.access to the entire breast parenchyma </li></ul><ul><li>4. integration to an imaging coil </li></ul><ul><li>The breast is compressed between 2 perforated plates with multiple horizontal holes that have MR visible markers serving as coordinates to calculate lesion location. The coil allows horizontal access to the breast either medially or laterally. </li></ul>
  51. 54. MR guided Stereotactic Biopsy Prone biopsy apparatus Supine biopsy apparatus
  52. 55. MR guided Biopsy
  53. 56. Radiofrequency <ul><li>Indications: </li></ul><ul><li>Single tumours </li></ul><ul><li>Not more than 1.5cm </li></ul><ul><li>Visible on US </li></ul><ul><li>Away from skin to avoid burns </li></ul><ul><li>Advantages: </li></ul><ul><li>Destroys small cancers before surgery </li></ul><ul><li>Shrinks tumours to avoid mastectomy </li></ul><ul><li>Reduce need for harsh systemic treatment </li></ul><ul><li>Provides a treatment option when surgery is not available or too risky. </li></ul>
  54. 57. Radiofrequency <ul><li>Under general anesthesia, an U/S guided needle-thin probe is inserted directly into the breast tumor and numerous prongs are deployed around the tumor. The prongs look like the ribs of an umbrella when fully deployed. Five of the prongs have thermometers at their tips. Electrical currents run through the device causing breast cancer molecules surrounding the tumor to move back and forth creating heat. </li></ul>
  55. 58. Radiofrequency <ul><li>Treatment is initiated at 10 watts of power for 2mins, after which power is increased in 5 watt increments every min until tissue impedence rises rapidly and power drops below 10 watts thus indicating complete coagulative necrosis of the lesion. </li></ul><ul><li>After 30 sec pause, a 2 nd phase of ttt is applied. </li></ul>
  56. 59. Thank You
  57. 60. Why MRS of the Breast? <ul><li>Imaging of the breast for cancer detection aims to fulfill two major goals: </li></ul><ul><li>-high sensitivity for detection of breast lesions </li></ul><ul><li>-and reliable differentiation of benign from malignant lesions (specificity). </li></ul><ul><li>In the results of several large MRM studies, sensitivities of 83%-96% for detection of breast carcinomas were reported. However the specificity remains variable ranging from 37% to 89%. </li></ul><ul><li>MR spectroscopy offers an adjunctive tool for lesion characterization in an effort to decrease unnecessary biopsy. </li></ul><ul><li>Although not a tool for screening an entire breast, it can play a role in improving specificity. </li></ul>
  58. 61. Indications Post operative Breast Dense Breast at high Risk Evaluation of axillary nodes MRS
  59. 62. Limitations Specificity Calcifications DCIS MRI Inflammation vs Ca
  60. 63. Mass Surrounding Non mass like Enhancement Morphology: Shape: round Margin: spiculated Enhancement pattern : rim Other: skin thickening, oedema Kinetic curve: Initial Rise: slow Delayed Phase: persistent Category : BIRADS 4 Pathology: Recurrent Invasive Duct Carcinoma Morphology: Distribution: diffuse Enhancement pattern : heterogenous asymmetrical Kinetic curve: Initial : rapid Delayed : persistent Category: BIRADS 4 Left Breast
  61. 64. Case 9: Lexicon Mass Focus Non mass like Enhancement Morphology: Shape: irregular Margin: spiculated Enhancement pattern : thick rim Other: skin thickening Kinetic curve: Initial Rise: rapid Delayed Phase: persistent Category : BIRADS 5
  62. 65. Case 8: Lexicon Multiple Masses & Foci Morphology: Shape: irregular Margin: spiculated Enhancement pattern : heterogeneous Other: skin thickening, mammary edema, chest wall edema, Lymph nodes Kinetic curve: Initial Rise: rapid Delayed Phase: plateau & persistent Category : BIRADS 5 Diagnosis: Recurrent Left Multicentric Invasive Ductal Ca
  63. 66. Follow up chemotherapy A 55 year old woman who underwent left conservative surgery 1year & 4 months ago followed by radio& chemotherapy. Ultrasonography of the right breast Mammography L R
  64. 67. Case 8 Axial T1 Axial T2 IR Saggital T2 Axial Subtraction
  65. 68. Case 8 MIP Axial Dynamic post contrast Fat suppressed FLASH, with signal-time analysis curve
  66. 69. Pre operative: a 43 year old lady presenting with a right breast lump & axillary swelling. The examination was performed during the 2nd week of the menstrual cycle.
  67. 72. <ul><li>Normal implants have a smooth, clearly defined margin, With a homogenous appearance. </li></ul><ul><li>Implants are encompassed by a thin fibrous capsule with low signal intensity. </li></ul><ul><li>Many implants show radial folds on MR which should not be confused with implant rupture . Very thin slices are needed to identify leaks from the implant shell. </li></ul>Fibrous capsule Fibrous capsule Radial folds Radial folds
  68. 73. MRI Appearance of Various Implants Single lumen Silicone Saline Water suppressed T2 WIs of single lumen silicon implant Axial T2 Fat Sat
  69. 74. MRI Appearance of Various Implants Single lumen Double lumen silicone saline
  70. 75. MRI Appearance of Various Implants Single lumen Double lumen Fat suppressed T2 W water suppressed T2 W
  71. 76. MRI Appearance of Various Implants Single lumen Double lumen Multicompartmental Outer saline & 2 inner silicone comaprtments
  72. 77. MRI Appearance of Various Implants Single lumen Double lumen Multicompartmental Single lumen silicone with saline Injection
  73. 78. MRI of Implant Failure
  74. 79. Fibrous capsule Fibrous capsule Radial folds Radial folds Normal Implants
  75. 80. MRI of Implant Failure Suspicious Findings: Loss of Round or Oval form Contour Bulge
  76. 81. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Capsular contracture occurs when the AP diameter of the implant is nearly equal to the TS diameter. (normally AP:TS ratio is 1:2)
  77. 82. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Axial T2 Fat Sat shows collapsed shell with residual saline The saline is usually absorbed, and linguine sign is not visible in saline implants
  78. 83. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Saline outside fibrous capsule
  79. 84. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Inverted tear drop C sign
  80. 85. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Key hole sign
  81. 86. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Linguine Sign
  82. 87. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture In double lumen implants, if the inner shell ruptures, a mixture between the saline and silicone occurs: The salad oil phenomenon.

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