Evolving Trends in Breast MRI

Dr Mohamed El Safwany, MD.

Intended learning outcome

• The student should learn at the end of this lecture evolving trends in breast imaging.

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“Conventional” Breast Imaging:

• Digital Mammography

• Breast ultrasound

• Breast MRI

Mammography

• Primary imaging modality in breast imaging and early detection/diagnosis of breast cancer

• Only imaging modality proven to reduce mortality from breast cancer

Digital Mammography

• Major recent advance in mammography• Markedly improved contrast resolution• Studies have shown increase in breast cancer

detection: in women with dense breasts, pre/perimenopausal and age < 50

• Decreased mean glandular dose: 3.7 mGy vs 4.7 mGy

• Increased efficiency of acquisition, storage and post processing of images

Breast Ultrasound

• Invaluable adjunct to mammography• Advances in high frequency, 14 MHz

transducers with 3D format has led to improved resolution and increased utilization

• Easy to perform and well tolerated• Safe: No radiation• Characterization of lesions, evaluation of clinical

findings, guidance for biopsies, assessment of the axilla and screening high risk women with dense breasts

Magnetic Resonance Imaging (MRI) of the Breast

• Well established as imaging exam of choice in evaluation of silicone breast implants for rupture

• Rapidly evolved into a highly valuable/clinically useful adjunctive imaging exam for breast cancer detection/diagnosis/preoperative planning

MRI - Strengths

• Morphologic and physiologic assessment with high sensitivity: most malignant lesions enhance following administration of contrast due to tumor neoangiogenesis

• Cross-sectional; No overlap of structures

• Ability to include the breast, chest wall and axillary region

Strengths (cont.)

• Uninfluenced by breast tissue density and complexity of fibroglandular pattern

• Safe: no radiation

Recent Technical Advances Making MRI Feasible in Clinical Practice:

– Dedicated tables and surface coils allowing rapid, high-resolution, dynamic imaging of both breasts at the same time

– Robust fat suppression techniques– MRI-compatible power injectors– Dedicated computer soft ware programs for

soft copy display, review and data analysis with 3D MIPS, angiogenesis maps and time intensity curves

– MRI-guided biopsy techniques

Sentinelle Table/Coil forBreast MRI

Breast MRI: Current Indications

• Preoperative assessment of newly diagnosed breast cancers

• Adjunctive screening in high-risk women• Identify occult tumor in women presenting with

axillary metastases • Monitor response to neoadjuvant chemotherapy

in women with advanced primary tumors• Screening women with silicone injections• Evaluation of silicone gel implants for rupture

• MRI is not indicated for population-based screening

• MRI is not indicated for the evaluation of mammographic or sonographic suspicious findings that otherwise should be biopsied

42 year old presenting with a large, palpable mass in the upper outer left breast:

Pre and post neoadjuvant chemotherapy

MRI-guided Breast Biopsy

• 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.

Future Advances in Breast MRI

• Breast MRI at 3T. Optimal breast imaging has not as yet been achieved or reported

• Breast MR Spectroscopy: dedicated coils and pulse sequences to determine choline and sodium levels which may be associated with malignancy.

• Mammography is the primary imaging modality in screening and diagnostic breast imaging

• Ultrasound invaluable and complimentary to mammography for lesion and clinical finding evaluation, guidance for biopsies, select screening

• Breast MRI plays important and increasing role in select settings: high-risk screening, preoperative assessment and occult malignancy detection

Text Book

• David Sutton’s Radiology

• Clark’s Radiographic positioning and techniques

Assignment

• Two students will be selected for assignment.

Question

• Describe the Breast MRI Current Indications?