Breast MRI at Lowell General Hospital. Jonas Berman, MD January 21, 2009. Lowell General Hospital. “In this defining moment, a change has come to Lowell General”. Breast Cancer Overview. >250,000 new cases diagnosed each year 2 nd leading cause of cancer deaths in women.
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Breast MRIat Lowell General Hospital Jonas Berman, MD January 21, 2009
Breast Cancer Overview • >250,000 new cases diagnosed each year • 2nd leading cause of cancer deaths in women
Of newly diagnosed cases of breast cancer, more than half are candidates for breast conservation
Various studies indicate that 15%-50% of patients with known breast cancer will have their management altered by further evaluation with ultrasound or breast MRI
Of these patients whose management is altered, 30%-50% will be demonstrated to have other foci of malignancy.
When an MRI of the breast identifies a lesion not originally identified on conventional imaging, a second, focused ultrasound will identify 50% of these lesions, which can then be biopsied conventionally. The other 50% need MRI guided biopsy.
Background: What is MRI? • Uses magnetic fields to produce detailed cross-sectional images of tissue structures • Uses injected contrast agents to distinguish fat, glandular tissue, lesions, etc. in the breast • Different factors contribute to the measured signal that determines the brightness of the tissues in the image • Contrast agent provides reliable detection of cancers and other lesions. • Screening MRI requires appropriate techniques and equipment (including dedicated breast MRI equipment) and experienced staff
Technical Requirements For Good Cancer Detection: • High-field breast MRI (1.5T or >) • Gadolinium-DTPA injection • Dedicated bilateral breast coil • Good fat suppression techniques • High-resolution 3D gradient echo pulse sequence
Contraindications Cardiac pacemakers, Ferromagnetic intracranial aneurysm clips Neurostimulators Cochlear implants Ferromagnetic implants, devices, foreign bodies, electronic devices. ACR practice guideline
Pregnancy/Lactation No known adverse effects Gadolinium does cross placenta into fetus minimally secreted in breast milk ACR practice guideline
Clinical Indications for Contrast enhancedBreast MRI: • Search for primary breast cancer in women with a positive axillary node • Staging of tumor extent in women with a known breast cancer – MRI most accurate • Search for multifocal, multicentric or bilateral breast cancer in women with a known breast cancer
Clinical Indications for Contrast enhancedBreast MRI: • Search for residual tumor shortly after surgery in patients with + margins • Evaluation for tumor recurrence after surgery and/or radiation • Monitoring tumor size and extent in neoadjuvant chemotherapy • Screening of high-risk women
Why Gadolinium is Essentialfor Cancer Detections T1W-Gradient-echo Pre- Gd T1W-Gradient-echo 2 minute Post Gd
Why Gadolinium is Essentialfor Cancer Detection T1W-Gradient-echo 2 minute Post Gd T1W-Gradient-echo Pre-Gd
Subtraction Image Sagital Maximum Intensity Projection (MIP)
Gadolinium Kinetics Enhancement Kinetics • Rate-how fast • Percent-how much in • Washout- how fast out
“Screening” MRI • Who is at High Risk? • Family history suggestive of inherited gene mutation; risk is calculated by assessment models/tools • Genetic testing for mutation in BRCA1/2, TP53, or PTEN • Review of clinical history • Treated for Hodgkin disease • LCIS, ALH • ADH, DCIS • High mammographic density • Personal history of breast cancer
Summary of ACS Recommendations (2007) • Recommend Annual MRI Screening (based on evidence) • BRCA mutation • 1st degree relative of BRCA carrier, but untested • Lifetime risk ~20-25% or greater, as defined by BRCAPRO or other models that are largely dependent on family history
Summary of ACS Recommendations cont’d • Recommend Annual MRI Screening (based on expert consensus opinion) • Radiation to chest (e.g. Hodgkin disease survivors) between ages 10-30 • Li Fraumeni syndrome,Cowden, Bannayan-Riley-Ruvalcaba syndromes
Summary of ACS Recommendations cont’d • Insufficient Evidence to Recommend For or Against MRI Screening • Lifetime risk 15-20%, as defined by BRCAPRO or other models that are largely dependent on family history • LCIS, ALH, ADH • Dense breast tissue • Personal history of breast cancer, including DCIS
Summary of ACS Recommendations cont’d • Recommend Against MRI Screening (based on expert consensus opinion) • Women at <15% lifetime risk
Breast Cancer Risks for Hypothetical Patients,Based on 3 Risk Models • Family History BRCAPRO Claus Tyrer-Cusick • 35year-old woman Mother BC 33 19% 36% 28% Maternal aunt BC 42 • 35-year-old woman 23% 24% 32% Paternal aunt BC 29, OC 49 Paternal grandmother BC 35 • 35-year-old woman 18% 24% 31% Paternal aunt BC 29 Paternal grandmother BC 35 • 35-year-old woman 13% 18% 23% Mother BC 51 Maternal aunt BC 60
Indications for Diagnostic MRI Lesion characterizations Mammographically dense breast Scar vs recurrent cancer Silicone augmented breast Neoadjuvant chemo – extent of disease Infiltrating lobular cancer – extent of disease Infiltrating ductal cancer – extent of disease Axillary adenopathy – primary unknown Post tissue reconstruction – recurrence Implant – integrity/ rupture ACR practice guideline
SILICONE IMPLANT EVALUATION • MRI shown to be superior in detecting rupture Goodman C M et al, Ann Plas Surg. 1998:41:577-586 • Mean Sensitivity Mammography 28% Ultrasound 59% MRI 78%
Indications for diagnostic MRI Invasion to deep fascia Contra lateral breast cancer Post lumpectomy residual disease – close margin on path Recurrence of cancer when other modalities inconclusive ACR practice guideline
MRI-GUIDED BREAST BIOPSY Appropriate for suspicious lesions found on MRI & not seen on mammography or US Equipment Needed: A dedicated breast coil A biopsy guidance system compatible with the breast coil and tissue sampling device A MR-compatible tissue sampling device: - 14 gauge cutting needle - 8-11 gauge vacuum-assisted sampling