1. Breast MRI Indications
2014 !
Sophie Taïeb, Luc Ceugnart
– Centre Oscar Lambret – Lille

2. MRI = Poor specificity
Ø 44 studies. 1985 – 2005. 3101 pts,
Ø Se : 90% [0.88-0.92]
Ø Sp : 72% [0.67-0.77]

3. Ø 69 studies. 1985 – 2010. 9298 pts, 9884 lesions.
Ø Se : 90% [0.88-0.92]
Ø Sp : 75% [0.70-0.79]
Ø LR+ : 3,64 [3-4,2]
Ø LR- : 0,12 [0.09-0.15]
Ø AUC : 0.91
Ø Point Q* : 0.84
MRI = Poor specificity
Medeiros LR et al. Breast Cancer
Research andTreatment 2011

4. False negative lesions
Late enhancement
Ø 5 % of cancers
ü DCIS.
Kuhl et al. Lancet 2007 : 44/89/7139 DCIS high grade
ü Well differentiated carcinomas : Mucinous
ü LIC
ü Fibrous carcinoma
Utility of a late sequence (> 8 mn)

5. False positive lesions
Benign lesions with early enhancement
Ø Focal enhancement
ü Normal breast (1st week or 2nd part of cycle)
ü Young fibroadenomas
ü Intra breast lymph nodes
ü Fat necrosis
ü Radial scar
ü Proliferative mastopathy with cysts
ü Phyllodes tumor(grade 1)
ü Post surgery (6 mois)
ü Post biopsy

6. Ø Diffuse enhancement
ü Normal breast (1st week or 2nd part of cycle)
ü Hormonal replacement therapy – OC – Mirena IUD
ü Proliferative mastopathy with cysts
ü Inflammatory breast
ü Post radiation therapy
False positive lesions
Benign lesions with early enhancement

7. 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)

8. Use adequat sequences
Ø Dedicated breast coil, Bilateral acquisition, 2nd week of cycle
Ø At least one unenhanced high-contrast sequence (T2 FSE)
Ø 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness < 4mm,
each sequences < 120 sec. At least 8 mn.
Ø Gadolinium-chelates 0,1mmol/kg – 2-3ml/s, saline flush
(20-30ml)
Ø Post processing : temporal substraction, dynamic analysis
MIP
Ø Not yet assessed in routine practice (2010) : DWI-MRI and H+
Spectroscopy

9. 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 Use Birads lexicon to describe lesions
Ø Respect indications

10. F A measure of the level of evidence (LoE) from 1a (highest) to 5
(lowest)
F Degree of recommendation (DoR) from A to D,
F Clinical recommendations not based on scientific evidence were
explicitly labelled as experts panel opinions (EPO).

11. Respect indications
Ø LoE 1,2 ; DoR A,B
ü No MRI
ü MRI first
ü MRI to specify CI

12. LoE-1A, DoR-A
1 - No MRI when biopsy can be performed
Ø Birads 3, 4 ou 5 Targets with CI = biopsy
ü Calcifications = vacuum assisted breast biopsy
ü Nodules = core needle biopsy or VABB
MRI if biopsy not feasable or if discordance between
image and VABB (EPO)
2 - No MRI in Young women, with risk < 20-30% for
all life, especially with dense breasts and especially
if anxious.

13. MRI first in screening of high-risk women
Ø Annual MRI : EPO
Ø Assessment screening program : recall rate < 10% EPO
Ø Begin at 30-year-old : LoE-2b, DoR-B
Dr L.Ollivier

14. MRI to specify CI :
Ø Evaluation of response to neoajuvant chemotherapy.
§ If perform : Pretreatment MRI always. LoE-1b; DoR-A
§ Very low enhancement after ttt is a sign of residual
lesion : LoE1, DoRA
§ In poor reponders based on clinical examination and CI
no MRI is not useful. EPO

15. MRI to specify CI :
Ø Evaluation of response to neoajuvant chemotherapy. (LoE-1b;
DoR-A)
Ø Breast cancer recurrence (LoE-1b; DoR-A)
ü Difficult Clinical examination, CI and Biopsy
ü BUT
* No screening by MRI
* MRI after CI + Biopsy (if target)
ü No FP after RT
ü FN occur

16. 1953
2001 : LIC Left breast : BCT
2003 : Mass
Biopsy : Normal breast

17. 1953
2001 : LIC Left breast : BCT
2003 : Mass
Biopsy : Normal breast
MRI : Fat necrosis : Birads 2
Follow-up : no recurrence

18. MRI to specify CI :
Ø Evaluation of response to neoajuvant chemotherapy. (LoE-1b; DoR-
A) .
Ø Breast cancer recurrence. (LoE-1b; DoR-A)
Ø Occult breast cancer (LoE-1b; DoR-A)
ü Not indicated in extensive metastatic disease (EPO)
ü If MRI negative avoided surgical treatment of
ipsilateral breast (LoE-2b; DoR-B)

19. 63-year-old, Left axillary lymph node
Ø LIC
Ø Negative CI
T2 MIP first Sub

20. § Mass 6mm
§ Birads 4 : round,
irregular margins,
Curve type 3

21. § Left lymph node : CLI
§ R : CCI + CCIS + LN

22. MRI to specify CI :
Ø Evaluation of response to neoajuvant chemotherapy. (LoE-1b; DoR-
A) .
Ø Breast cancer recurrence. (LoE-1b; DoR-A)
Ø Occult breast cancer (LoE-1b; DoR-A)
Ø Breast implants: augmentation or reconstruction
ü MRI is not a screening tool (LoE-1, DoR-A)
ü Implant rupture ? Non contrast MRI (LoE-1a, DoR-
A)
ü Recurrence ? Contrast-enhancement MRI (LoE-2,
Dor-B)

23. Breast implant rupture
Breast implant capsule
Breast implant wall
Intracapsular Rupture
Extracapsular rupture
Courtesy Dr C.Balleyguier - IGR

24. Intra capsular rupture

25. Extra capsular rupture
Courtesy Dr C.Balleyguier - IGR

26. § 56 year-old
§ Breast reconstruction 3 years ago
§ Direct trauma (Fall off a bike)
§ US : Intracapsular rupture ?
MRI

27. Silicone breast implant
MRI = Intracapsulare rupture
T1
T2
STIR

28. Silicone breast implant
MRI = Intracapsulare rupture
T1
T2
STIR

29. T2
Water & Fat sat

30. Respect indications
Ø LoE 1,2 ; DoR A,B
ü No MRI when biopsy can be performed. Young women
ü MRI first : Screening of high-risk women
ü MRI to specify CI : Evaluation of response to neoajuvant
chemotherapy, Breast cancer recurrence, Breast implants,
Occult primary breast cancer.

31. Respect indications
Ø LoE 1,2 ; DoR A,B
ü No MRI when biopsy can be performed. Young women
ü MRI first : Screening of high-risk women
ü MRI to specify CI : Evaluation of response to neoajuvant
chemotherapy, Breast cancer recurrence, Breast implants,
Occult primary breast cancer
Ø LoE = 3 – EPO : All MRI as « problèmes solving » :
Nipple discharge, Paget disease, AD seen on one incidence…
MRI allows to highlight carcinoma not seen on CI J

32. § 46 year-old
§ Paget disease
§ CI : negative
MRI

33. § 46 year-old
§ Paget disease
§ CI : negative
§ MRI : 2 biopsies IDC, DCIS
§ P : DCI + comedo carcinoma, 1N+ (GS), GSBR 7,
Ki67 35%, RE+, RP-, Her2+

34. 41 y-o - Nurse
Normal physical examination
Mother with breast carcinoma under 50 years-old
1st mammography

35. US : no lesions seen
BiRads 3 or MRI ?

36. BiRads 2

37. MRI = PROBLEM SOLVING J

38. CONTRALATERAL BREAST
3rd sequence postC T2FS
Ø BiRads 3
Ø US : not seen
Washin card

39. Follow up 4 months : Persistence of lesion
Biopsy
Failure

40. 2 Months later : SURGERY
MRI wire localization
ü HYPERPLASIA without atypical cells
MRI = Problem creating L

41. Respect indications
Ø LoE 1,2 ; DoR A,B
ü No MRI when biopsy can be performed. Young women
ü MRI first : Screening of high-risk women
ü MRI to specify CI : Evaluation of response to neoajuvant
chemotherapy, Breast cancer recurrence, Breast implants,
Occult primary breast cancer
Ø LoE 2–DoR=B : Staging before treatment planning
Ø LoE = 3 – EPO : All MRI as « problèmes solving » :
Nipple discharge, Paget disease, AD on one incidence…

42. Staging before treatment planning
Change of treatment planning due to MRI :
à Biopsy of additional lesions +++ to avoided
mastectomy due to FP - LoE-1a, DoR-A
(5) – Breast cancer in women < 40 ans

43. Ø If MRI = more TM & thus increase overall survival :
this is good news
Ø M.Morrow ( Editorial JAMA 2004)
Technological breakthrough = Go back to 70’ for
treatment.
Staging before treatment planning

44. Patientes randomisées entre 1975 et 1985

45. Ø 50 / 237 – 1996-2011
Ø 10811 pts
Ø MRI :
ü 20% ipsilat. lesions more: PPV 59 à 74% à biopsies
§ Wider excision in 12,8% but 6,3% useless
§ Local recurrences rate after BCT : 0.5-1% per year
ü 5,5% contralat : PPV 27 à 47% à biopsies
Ø Patients outcome ??

46. à 01/2013
Ø 4 studies – 3169 pts, 3180 lesions
Ø 1833 no MRI, 1347 MRI. 1 randomized (COMICE), 3 no
Ø Median follow-up 2.9 years [1.6-4.5]
ü 64/3169 local recurrences (2%)
MRI : 1.8%; No MRI : 2.2% NS
ü 93/2708 distant recurrences (3.4%)

47. 8-year probability :
§ LR-free survival for MRI : 97% [95-98] vs no MRI = 95% [93-97] P=.87
§ DR-free survival for MRI : 89% [83-93] vs no MRI = 93% [90-95] P =.37

48. Ø Preoperative MRI in routine staging does not reduce
the risk of LR or DR
Ø Study limitations :
ü Only 4 studies
ü Only 1 randomized
ü Only 8 years probability follow-up
ü Contralateral breast : no information

49. Staging before treatment planning
Change of treatment planning due to MRI :
à Biopsy of additional lesions +++ to avoided
mastectomy due to FP - LoE-1a, DoR-A
(5) – Breast cancer in women < 40 ans

50. Ø LoE 1,2 ; DoR A,B
ü No MRI when biopsy can be performed. Young women
ü MRI first : Screening of high-risk women
ü MRI to precise CI : Breast cancer recurrence, breast
implants, Occult primary breast cancer, Evaluation of
response to neoajuvant chemotherapy .
Ø LoE = 2 – DoR=B : Staging before treatment
planning
Invasive LC, High-risk patients, discrepancy in size between
mammo and US with expected impact on treatment decision
Ø LoE = 3 – EPO : All MRI as « problemes solving » :
Nipple discharge, Paget disease, AD on one incidence…
MRI as problemes creating…
In summary

51. Key points
1. Respect indications – Poor specificity !!
2. Respect technical conditions
3. Use BiRads lexicon (allowed Birads 0)
No more problems after MRI than before
ü Explain it to patients
ü Explain it to referent colleagues
And do it BEFORE to perform Breast MRI