Breast MRI of Invasive Cancer · before Δsurgical approach zAdditional breast tumour foci • 15-37% ipsilateral breast • 3-5% contralateral breast zAlters clinical management

Breast MRI of Invasive Cancer

Breast MRI of Invasive Breast MRI of Invasive CancerCancer

Audrey Spielmann, MDAudrey Audrey SpielmannSpielmann, MD, MDBC Surgery Oncology Breast Cancer Update BC Surgery OncologyBC Surgery Oncology Breast Cancer Update Breast Cancer Update

OutlineOutlineOutline

TechniqueIndicationsCasesPre-op Breast MRIConclusion

TechniqueTechniqueIndicationsIndicationsCasesCasesPrePre--op Breast MRIop Breast MRIConclusion Conclusion

OutlineOutlineOutline

Excluded• Screening• Post-op MRI• DCIS• Breast Implant

integrity

ExcludedExcluded•• ScreeningScreening•• PostPost--op MRIop MRI•• DCISDCIS•• Breast Implant Breast Implant

integrityintegrity

Name: ____________________Date of Birth: ________________Referring Physician: __________________

Reason for Exam:_____ Implant Assessment _____Enlarged lymph glands under arm_____ Breast Lump ( right / left ) _____Known breast cancer ( R / L)_____ Nipple Discharge ( right / left ) _____ Other: __________________________

Previous MammogramWhere/When: _______________________Previous Ultrasound:Where/When:______________________

Name: ____________________Date of Birth: ________________Referring Physician: __________________

Reason for Exam:_____ Implant Assessment _____Enlarged lymph glands under arm_____ Breast Lump ( right / left ) _____Known breast cancer ( R / L)_____ Nipple Discharge ( right / left ) _____ Other: __________________________

Previous MammogramWhere/When: _______________________Previous Ultrasound:Where/When:______________________

TechniqueBreast MRI Questionnaire

TechniqueTechniqueBreast MRI Questionnaire

Previous Breast Surgery: ( yes / no )Where/When: _____________R/ L breast Benign / Malignant

Pre-menopausal ( yes / no ) First day of LMP: _____________Exam should be scheduled for Day 7-14 of cycle

Post-menopausal ( yes / no ) On HRT? _________________HRT should be stopped 3 months prior to exam—consult your physician

Do you have a family history of breast cancer (if yes, please indicate age of diagnosis)Mother _____ Sister _____ Grandmother _____ Aunt _____ Daughter ______

Previous Breast Surgery: ( yes / no )Where/When: _____________R/ L breast Benign / Malignant

Pre-menopausal ( yes / no ) First day of LMP: _____________Exam should be scheduled for Day 7-14 of cycle

Post-menopausal ( yes / no ) On HRT? _________________HRT should be stopped 3 months prior to exam—consult your physician

Do you have a family history of breast cancer (if yes, please indicate age of diagnosis)Mother _____ Sister _____ Grandmother _____ Aunt _____ Daughter ______





Have you had any of the following treatments(If yes, please indicate where & when)

_____ Lumpectomy _____ Mastectomy_____ Chemotherapy _____ Radiation_____ Tamoxifen ______ HRT / BCP_____ Needle biopsy

Patient Signature: ______________________________________Date: _______________

Have you had any of the following treatments(If yes, please indicate where & when)

_____ Lumpectomy _____ Mastectomy_____ Chemotherapy _____ Radiation_____ Tamoxifen ______ HRT / BCP_____ Needle biopsy

Patient Signature: ______________________________________Date: _______________

TechniqueBreast Coil

TechniqueTechniqueBreast CoilBreast Coil

Technique Positioning

Technique Technique PositioningPositioning

TechniqueSequences

TechniqueTechniqueSequencesSequences

Coronal STIRAx FSE T2 or STIR3D VIBRANT with fat saturation-precontrast, immediate post injection and 3 more consecutive runs(scantime <1.5 minutes)Post-processing-subtraction

Coronal STIRCoronal STIRAx FSE T2 or STIRAx FSE T2 or STIR3D VIBRANT with fat saturation3D VIBRANT with fat saturation--precontrastprecontrast, immediate post injection , immediate post injection and 3 more consecutive and 3 more consecutive runs(scanruns(scantime <1.5 minutes)time <1.5 minutes)PostPost--processingprocessing--subtractionsubtraction

Breast MRI BI-RADS LexiconBreast MRI Breast MRI BIBI--RADS LexiconRADS Lexicon

Lesion Morphology• Mass (3D)• Area of non-mass-like

enhancement• Focus (<5mm)

Enhancement Kinetics

Lesion MorphologyLesion Morphology•• Mass (3D)Mass (3D)•• Area of nonArea of non--massmass--like like

enhancementenhancement•• Focus (<5mm)Focus (<5mm)

Enhancement KineticsEnhancement Kinetics

MRI BI-RADS Lexicon Mass-Irregular shape

MRI BIMRI BI--RADS Lexicon RADS Lexicon MassMass--Irregular shapeIrregular shape

MRI BI-RADS Lexicon Mass-Irregular shape

MRI BIMRI BI--RADS Lexicon RADS Lexicon MassMass--Irregular shapeIrregular shape

57 yoMammo +, US Bx

57 yoMammo +, US Bx

MRI BI-RADS Lexicon Asymmetric EnhancementMRI BIMRI BI--RADS Lexicon RADS Lexicon Asymmetric EnhancementAsymmetric Enhancement

45 yoBx DCIS

45 yoBx DCIS

Breast MRIEnhancement Kinetics

Breast MRIBreast MRIEnhancement KineticsEnhancement Kinetics

angiogenesisangiogenesisangiogenesis

Breast MRITime-signal intensity curve

Breast MRIBreast MRITimeTime--signal intensity curvesignal intensity curve

64% Malignant64% Malignant64% Malignant

87% Malignant87% Malignant87% Malignant

94% Benign94% Benign94% Benign

Kuhl CK et al. Radiology 2000;215:267-279KuhlKuhl CK et al. Radiology 2000;215:267CK et al. Radiology 2000;215:267--279279

http://radiology.rsnajnls.org/content/vol211/issue1/images/large/r99ap38l1x.jpeg

Breast MRITime-signal intensity curve

Breast MRIBreast MRITimeTime--signal intensity curvesignal intensity curve

Kuhl CK et al. Radiology 2000;215:267-279KuhlKuhl CK et al. Radiology 2000;215:267CK et al. Radiology 2000;215:267--279279

http://radiology.rsnajnls.org/content/vol211/issue1/images/large/r99ap38g5a.jpeg

http://radiology.rsnajnls.org/content/vol211/issue1/images/large/r99ap38g5c.jpeg

http://radiology.rsnajnls.org/content/vol211/issue1/images/large/r99ap38g5d.jpeg

http://radiology.rsnajnls.org/cgi/content/full/211/1/101/F5G

IndicationsACR practice guidelines (2008)

IndicationsIndicationsACR practice guidelines (2008)ACR practice guidelines (2008)

Screening• High risk patients• Contralateral breast (3-5%

occult malignancy)• Breast Augmentation

ScreeningScreening•• High risk patientsHigh risk patients•• ContralateralContralateral breast (3breast (3--5% 5%

occult malignancy)occult malignancy)•• Breast AugmentationBreast Augmentation

Indications Breast Augmentation

Indications Indications Breast AugmentationBreast Augmentation

54 y womanImplants 20 y agoPalpable mass LMammo +US bx

54 y womanImplants 20 y agoPalpable mass LMammo +US bx



Extent of disease• Multifocality and Multicentricity• Invasion deep to fascia• Postlumpectomy + margins• Neoadjuvant chemotherapy

Extent of diseaseExtent of disease•• MultifocalityMultifocality and and MulticentricityMulticentricity•• Invasion deep to fasciaInvasion deep to fascia•• PostlumpectomyPostlumpectomy + margins+ margins•• NeoadjuvantNeoadjuvant chemotherapychemotherapy

Additional evaluation of clinical/imaging findings• Recurrence• Occult Breast Cancer• Lesion characterization• PO tissue reconstruction• MRI-guided biopsy

Additional evaluation of Additional evaluation of clinical/imaging findingsclinical/imaging findings•• RecurrenceRecurrence•• Occult Breast CancerOccult Breast Cancer•• Lesion characterizationLesion characterization•• PO tissue reconstructionPO tissue reconstruction•• MRIMRI--guided biopsyguided biopsy



Breast MRI Indications Pre-operative Evaluation

Breast MRI Indications Breast MRI Indications PrePre--operative Evaluationoperative Evaluation

Tumour size and locationMultifocality & Multicentricity(occult disease 15-37%)Chest wall or pectoralis muscle invasion, nipple or skin invasionAxillary or internal mammary LNMetastasis

TumourTumour size and locationsize and locationMultifocalityMultifocality & & MulticentricityMulticentricity(occult disease 15(occult disease 15--37%)37%)Chest wall or Chest wall or pectoralispectoralis muscle muscle invasion, nipple or skin invasioninvasion, nipple or skin invasionAxillaryAxillary or internal mammary LNor internal mammary LNMetastasisMetastasis

Ipsilateral cancer was found on MRI in 19/70 (27%)• 20% same quadrant• 4% different quadrant• 3% same and different

Strong family Hx or infiltrating lobular histology

IpsilateralIpsilateral cancer was found on MRI cancer was found on MRI in 19/70 (in 19/70 (27%27%))•• 20% same quadrant20% same quadrant•• 4% different quadrant4% different quadrant•• 3% same and different3% same and different

Strong family Strong family HxHx or infiltrating or infiltrating lobular histologylobular histology

Liberman L et al. AJR 2003; 180:901-910LibermanLiberman L et al. AJR 2003; 180:901L et al. AJR 2003; 180:901--910910









50 yo woman77 yo mother dx metastatic breast

CaThickening L UOQMammo -, US - in area but lesion

in L UIQUS Bx→ infiltrating lobular Ca

50 50 yoyo womanwoman77 77 yoyo mother mother dxdx metastaticmetastatic breast breast

CaCaThickening L UOQThickening L UOQMammoMammo --, US , US -- in area but lesion in area but lesion

in L UIQin L UIQUS US BxBx→→ infiltrating lobular Ca infiltrating lobular Ca







Lobular CarcinomaLobular CarcinomaLobular Carcinoma

42 y womanPalpable L breast mass

42 y womanPalpable L breast mass







Pre-op Breast MRIChest Wall invasion

PrePre--op Breast MRIop Breast MRIChest Wall invasionChest Wall invasion

41 y womanPalpable L breast mass UOQBx infiltrating poorly-differentiated ductal carcinoma

41 y womanPalpable L breast mass UOQBxBx infiltrating infiltrating poorlypoorly--differentiated differentiated ductalductal carcinomacarcinoma

Breast MRI Indications Contralateral breast screening pre-op

Breast MRI Indications Breast MRI Indications ContralateralContralateral breast screening prebreast screening pre--opop

3-5% synchronous contralateralbreast Ca on MRI only • 30/969 (3%) contralat breast Ca• 121/969 (12.5%) Bx• 30 + bx(24.8%)

18 invasive Ca12 DCISAll node negative

33--5% synchronous 5% synchronous contralateralcontralateralbreast Ca on MRI only breast Ca on MRI only •• 30/969 (3%) 30/969 (3%) contralatcontralat breast Cabreast Ca•• 121/969 (12.5%) 121/969 (12.5%) BxBx•• 30 + bx(24.8%)30 + bx(24.8%)

18 invasive Ca18 invasive Ca12 DCIS12 DCISAll node negativeAll node negative

Lehman C et al N Engl J Med 2007; 356:1295Lehman C et al N Lehman C et al N EnglEngl J Med 2007; 356:1295J Med 2007; 356:1295

Risk of occult Ca in contralateralbreast 1 year post neg MRI 0.3%Risk of occult Ca in Risk of occult Ca in contralateralcontralateralbreast 1 year post breast 1 year post negneg MRI 0.3%MRI 0.3%

Lehman C et al N Engl J Med 2007; 356:1295Lehman C et al N Lehman C et al N EnglEngl J Med 2007; 356:1295J Med 2007; 356:1295

Breast MRI Indications Contralateral breast screening pre-op

Breast MRI Indications Breast MRI Indications ContralateralContralateral breast screening prebreast screening pre--opop

Additional breast tumour foci• 15-37% ipsilateral breast• 3-5% contralateral breastAlters clinical management 10-31%Biopsy of suspicious lesions before Δ surgical approach

Additional breast Additional breast tumourtumour focifoci•• 1515--37% 37% ipsilateralipsilateral breastbreast•• 33--5% 5% contralateralcontralateral breastbreastAlters clinical management 10Alters clinical management 10--31%31%Biopsy of suspicious lesions Biopsy of suspicious lesions before before ΔΔ surgical approachsurgical approach

Pre-op Breast MRIRadiological PerspectivePrePre--op Breast MRIop Breast MRIRadiological PerspectiveRadiological Perspective

Conflicting endorsementCleveland clinic-fully promotes pre-op breast MRI without restriction327 patients-25% pts occult but suspicious lesions13% pts occult and separate tumours75% no additional suspicious foci

Conflicting endorsementConflicting endorsementCleveland clinicCleveland clinic--fully promotes prefully promotes pre--op breast MRI without restrictionop breast MRI without restriction327 patients327 patients--25% pts occult but 25% pts occult but suspicious lesionssuspicious lesions13% pts occult and separate 13% pts occult and separate tumourstumours75% no additional suspicious foci75% no additional suspicious foci

J Crowe, The Breast Journal, Vol 15 # 1, 2009, p52-60

Pre-op Breast MRISurgical Perspective

PrePre--op Breast MRIop Breast MRISurgical PerspectiveSurgical Perspective

267 patients invasive CaSurgical management Δ to wider/separate excision or mastectomy in 26% (69/267)Confirmed on path that necessary 71% (49/267)46% lobular Ca altered management

267 patients invasive Ca267 patients invasive CaSurgical management Surgical management ΔΔ to to wider/separate excision or wider/separate excision or mastectomy in 26% (69/267)mastectomy in 26% (69/267)Confirmed on path that necessary Confirmed on path that necessary 71% (49/267)71% (49/267)46% lobular Ca altered management46% lobular Ca altered management

Bedrosian I et al, Cancer 2003, Vol 98, 468-473



Occult primary malignancyBRCA1/2/other genetic mutationMajor discrepancy between mammo and US

(ILC, very dense breasts)

Occult primary malignancyOccult primary malignancyBRCA1/2/other genetic mutationBRCA1/2/other genetic mutationMajor discrepancy between Major discrepancy between mammomammo and USand US

(ILC, very dense breasts)(ILC, very dense breasts)



M Morrow, Nature Clin Practice Oncology Feb2009 Vol 6 No2

Meta-analysis observational studies (2610 women)Improved surgical planningReduce re-excision surgeryReduce local recurrence

Not substantiated by trialsAdditional foci tx with radiation & chemotherapy

MetaMeta--analysis observational studies analysis observational studies (2610 women)(2610 women)Improved surgical planningImproved surgical planningReduce reReduce re--excision surgeryexcision surgeryReduce local recurrenceReduce local recurrence

Not substantiated by trialsNot substantiated by trialsAdditional foci Additional foci txtx with radiation & with radiation & chemotherapychemotherapy

Houssami N & Hayes D, CA Cancer J Clin 2009HoussamiHoussami N & Hayes D, CA Cancer J N & Hayes D, CA Cancer J ClinClin 20092009

Pre-op Breast MRIAssumptions

PrePre--op Breast MRIop Breast MRIAssumptionsAssumptions

15/18 studies quoted in the meta-analysis ≤ 2004 back to 19953/18 > 2004 Marked improvement in image quality

15/18 studies quoted in the meta15/18 studies quoted in the meta--analysis analysis ≤≤ 2004 back to 19952004 back to 19953/18 > 2004 3/18 > 2004 Marked improvement in image Marked improvement in image qualityquality

Pre-op Breast MRIAssumptions

PrePre--op Breast MRIop Breast MRIAssumptionsAssumptions


Increased risk of recurrenceIncreased risk of recurrenceIncreased risk of recurrence

Involvement of surgical marginsExtensive cancer ID clinically or mammographicallyPresence of locally advanced Ca

Involvement of surgical marginsInvolvement of surgical marginsExtensive cancer ID clinically or Extensive cancer ID clinically or mammographicallymammographicallyPresence of locally advanced CaPresence of locally advanced Ca





Extent of cancer underestimated clinically and mammographically

Pre-op Breast MRIPrePre--op Breast MRIop Breast MRI

ProsProsProsExtent (MF vs MC)Screen CL breastChest wall invasionPatient & Surgeon reassured

Extent (MF Extent (MF vsvs MC)MC)Screen CL breastScreen CL breastChest wall invasionChest wall invasionPatient & Surgeon Patient & Surgeon reassuredreassured

ConsConsConsAdditional ImagingFurther biopsyDelay in surgeryMore pt anxietyMore extensive lumpectomy or conversion to mastectomy

Additional ImagingAdditional ImagingFurther biopsyFurther biopsyDelay in surgeryDelay in surgeryMore pt anxietyMore pt anxietyMore extensive More extensive lumpectomy or lumpectomy or conversion to conversion to mastectomymastectomy

Pre-op Breast MRI will find otherwise occult ipsilateral and contralateraltumour fociMust bx MRI suspicous lesionsPatient awareness that further bx and delay in surgeryNegative MRI for MC/CL disease reassuring

PrePre--op Breast MRI will find otherwise op Breast MRI will find otherwise occult occult ipsilateralipsilateral and and contralateralcontralateraltumourtumour focifociMust Must bxbx MRI MRI suspicoussuspicous lesionslesionsPatient awareness that further Patient awareness that further bxbx and and delay in surgerydelay in surgeryNegative MRI for MC/CL disease Negative MRI for MC/CL disease reassuringreassuring

Pre-op Breast MRIConclusion

PrePre--op Breast MRIop Breast MRIConclusionConclusion

Particularly helpful• Axillary nodes-occult primary• Genetic Ca• Lobular Carcinoma• Very dense breasts/young

patients

Particularly helpfulParticularly helpful•• AxillaryAxillary nodesnodes--occult primaryoccult primary•• Genetic CaGenetic Ca•• Lobular CarcinomaLobular Carcinoma•• Very dense breasts/young Very dense breasts/young

patients patients



More research (randomized, controlled prospective trials)needed to study longterm impact on local recurrence, morbidity and mortality

More research More research (randomized, (randomized, controlled prospective trials)controlled prospective trials)needed to study needed to study longtermlongterm impact impact on local recurrence, morbidity on local recurrence, morbidity and mortalityand mortality



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Documents

Breast MRI of Invasive Cancer · before Δsurgical approach zAdditional breast tumour foci • 15-37% ipsilateral breast • 3-5% contralateral breast zAlters clinical management