New Breast MR Imaging Sophie Taïeb, Luc Ceugnart Anticancer center Oscar Lambret - Lille -
New Breast MR Imaging
Sophie Taïeb, Luc Ceugnart
Anticancer center Oscar Lambret - Lille -
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 Respect indications
Ø Use Birads lexicon to describe lesions
Right Breast : Mass BiRads 5
• US: mass 25 mm • IDC grade 3 • RE+, RP-, Her2 -, Ki67 25-30%
35 y-o. BRCa2. Yearly MRI
Right breast 6h : DCIS
• Pas de traduction echo- mammographique
Right mastectomy
Ø IDC 16 mm Ø DCIS 11 mm
Ø 1N+ / 13 N
MRI allows to highlight carcinoma not
seen on mammo or US J
41 y-o - Nurse Normal physical examination Mother with breast carcinoma under 50 years-old 1st mammography
US : no lesions seen
BiRads 3 or MRI ?
BiRads 2
MRI = PROBLEM SOLVING J
CONTRALATERAL BREAST
3rd sequence postC T2FS
Ø BiRads 3 Ø US : not seen
Washin card
Follow up 4 months : Persistence of lesion Biopsy
Failure
2 Months later : SURGERY MRI wire localization
Ø HYPERPLASIA without atypical cells
MRI = Problem creating L
Ø Safe : No toxicity (gadolinium-chelates)
Ø High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease
Ø Good reproducibility : Inter et Intra observers
Ø Low coast : Money, Medical’s and Patient’s time
Ø Easy comparison with gold standards ü Mammo – US ü Biopsy - Surgery ü Histopathology
The breast MRI we need
Ø Safe : No toxicity (gadolinium-chelates)
Ø High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease
Ø Good reproducibility : Inter et Intra observers
Ø Low coast : Money, Medical’s and Patient’s time
Ø Easy comparison with gold standards ü Mammo – US ü Biopsy - Surgery ü Histopathology
The breast MRI we need
MRI = Poor specificity
Ø 44 studies / 251 : 1985 - 2005
Ø Se : 90% [0.88-0.92]
Ø Sp : 72% [0.67-0.77]
Ø 11 studies (1994-2007) – No randomised studies Ø 2 mutations (727), 9 mutations + risk > 15% for all life (4939)
Ø 218 cancers : 3.5% (45) - 2% (171) - 20% DCIS - 60%N+ (126)
Ø Se : Mammo 14-59% ; MRI 51-100% Ø Sp : Mammo 91-100% ; MRI 79-98%
Ø 50 / 237 – 1996-2011 Ø 10811 women Ø Extension surgery in 12,8% but useless in 6,3% of cases Ø Miss information about overall survival
Ø MRI : ü 20% homolat lesions. PPV of cancer : 59-74% à need biopsy PPV : 75% if > 1,5T ; 59% if < 1,5T
ü 5,5% controlat. PPV of cancer : 27-47% à need biopsy PPV : 40% if > 1,5T ; 19% if < 1,5T
Ø Adequat sequences : 2nd Week of menstrual cycle ü At least one unenhanced high-contrast sequence (T2 FSE) ü 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness
< 4mm, < 120 sec. ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)
Improve specificity : 3T MRI ?
Ø Adequat sequences : 2nd Week of menstrual cycle ü At least one unenhanced high-contrast sequence (T2 FSE) ü 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness
< 4mm, < 120 sec. ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)
Ø Centre Oscar Lambret - 3T : 3D Vibrant (GE) ü 5 x 80 secondes ü Pixel 0,66 mm2, Thickness 2,2mm, No Gap. ü S1 – begining injection 20sec. before the end, 4 post injection
Improve specificity : 3T MRI ?
Ø Adequat sequences : 2nd Week of menstrual cycle ü At least one unenhanced high-contrast sequence (T2 FSE) ü 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness
< 4mm, < 120 sec. ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)
Ø Centre Oscar Lambret - 3T : 3D Vibrant (GE) ü 5 x 80 secondes ü Pixel 0,66 mm2, Thickness 2,2mm, No Gap. ü S1 – begining injection 20sec. before the end, 4 post injection
Ø No studies demonstrate 3T > 1,5T ü Best spatiale resolution
ü Best temporal resolution : 15 - 20 mn T1 + T2 + DWI-w + 3D dynamic + Late Sequence (DCIS)
Improve specificity : 3T MRI ?
Improve specificity : DWI-MRI ?
Ø à 2009 : 13 / 65 études Ø 615 Cancers, 349 LB Ø b 1000 -Se : 0.84 [0.8-0.87]; Sp 0.84 [0.79-0.88]
ü 93 women, 101 lesions. 3T, b0, b600.
ü 33 BL : 9 FA, 3 intraductal Papillomas, 4 Fibrocystic L, 4 sclerosing aden. 2 ADHL, 11 areas of benign breast tissue
ü 68 K : 23 IDC, 26 IDC+DCIS, 9 DCIS, 6 ILC, 4 others
• 27 y-‐o. Pregnant : 8 Weeks • Le6 B : IDC Grade 3 RE-‐, RP-‐, Her2 -‐.
S3 Native 3
Diffusion b 1000 ADC
• 27 y-‐o. Pregnant : 8 Weeks • Le6 B : IDC Grade 3 RE-‐, RP-‐, Her2 – • Right B : ?
ADC: 2, ADC: 0,86.10-3 ADC: 1,26.10- 3
• 27 y-‐o. Pregnant : 8 Weeks • LB : IDC Grade 3 RE-‐, RP-‐, Her2 – • RB : ?
ADC: 2, ADC: 0,86.10-3 ADC: 1,26.10- 3
ADENOSIS
• 27 y-‐o. Pregnant : 8 Weeks • LB : IDC Grade 3 RE-‐, RP-‐, Her2 – • RB : ?
54 y-‐o. MulKfocalité on mammography ?
RB : 2nd lesion : Birads 5
54 y-‐o. MulKfocalité on mammography ?
RB : 2nd lesion : Birads 5
54 y-‐o. MulKfocalité on mammography ?
RB : 2nd lesion : Birads 5
54 y-‐o. MulKfocalité on mammography ?
LB :
54 y-‐o. MulKfocalité on mammography ?
LB : Lymph node
Artefacts fréquents….
Courtesy Dr C.Balleyguier
Improve specificity : Contrast media ?
Support: Bracco
Ø Centers 17 : 07/2007 – 05/2009 Ø 162 Mammo ou US : Birads 3, 4, 5 (biopsy needed)
Ø 82 Gadobenate Dimeglumine / 80 Gadopentate Dimeglumine Ø 2nd MRI > 2 days; < 7 days
Ø 136 patients with both. GB : 7 atopic reactions, GP : 6 Ø Independant 2nd reading : 3 readers + 4th review reader
Ø 136 double examinations : 216 lesions
Ø 144 cancers : ü 87 IDC, 30 ILC, 5 both, 5 others ü 13 DCIS, 3 LN, 1 mixte
Ø 52 Benign lesions
Ø 20 Birads3 : follow-up
Results : 3 readers Ø Cancer detection rate : GB 91.7, 93, 94.4% > GP 79.9, 80.6, 83.3%
Ø Se : GB 91.1, 94.5, 95.2% > GP 81.2, 82.6, 84.6%
Ø Sp : GB 99, 98.2, 96.9% > GP 97.8, 96.9, 93.8%
50 y-o, DCIS
Use Birads to describe lesions
Objective : BiRads : 0? 1? 2? 3? 4? or 5?
1. Density : 1 to 4 ≈ Mammography 2. Background Parenchymal enhancement
Use Birads to describe lesions
Objective : BiRads : 0, 1, 2, 3, 4 ou 5 ?
1. Density : 1 to 4 ≈ Mammography 2. Background Parenchymal enhancement 3. Lesion analysis – morphology
ü Detection : 1st post contrast sequence (soust – MIP) ü Analysis : 2nd post contrast sequence (native – MIP)
3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement
Conclusion:BiRads 0? 2? 3? 4? 5 ?
3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement
Conclusion:BiRads 0? 2? 3? 4? 5 ?
Focus
3T, GB
BiRads : 0, 2, 3, 4, 5 ?
45 y-o, 29 y-o, 54 y-o.
3T, GB
BiRads : 0, 2, 3, 4, 5 ?
3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement
BiRads Mammo & US : According to images alone BiRads MRI : According to MR images and CI
and 2nd look US and context (and intuition?)
Conclusion:BiRads 0? 2? 3? 4? 5 ?
45 y-o, BRCA2 2-2011
29 y-o, BRCA2 – 1st IRM – 1/2010
54 y-o. IDC bi-focal
BiRads : 0, 2, 3, 4, 5 ?
45 y-o, BRCA2, CI normal
2009 2-2011 BiRads 3
45 y-o, BRCA2 CI normal
2009 2-2011 BiRads 3 6-2011
1-2013
Birads 2
29 y-o, BRCA2 – 1st IRM – 1/2010
2nd look Mammo & US normal Birads3 D Birads3 G
29 y-o, BRCA2 – 1st IRM – 1/2010 4/2010
29 y-o, BRCA2 – 1st IRM – 1/2010 4/2010 : IDC, G3, ER+, PR-, Her2-, N-
8 mm – BiRads6- IDC BiRads 6 - IDC
§ 54 y-o, Left breast : IDC
4,1mm
54 y-o Left breast : IDC
FOCUS Birads 4 : IDC 4,1mm
Retraction + lesions Birads 6 § 54 y-o, Left breast : IDC
Kinetic curves
Ø After morphological analysis (Kuhl, AJR 2005)
Ø After morphological analysis (Kuhl, 2005)
57% in carcinoma 5% in benign Lesion
Ø (Kuhl, 1999)
Type 3
Kinetic curves
Ø After morphological analysis (Kuhl, 2005)
34 % : K 9% : K 12% : BL 83% : BL
Type 1
Type 2
Kinetic curves
Foci or UBO (unidentify bright object)
Ø Birads2 if : ü < 5 mm, ü No associated findings ü Not menopausal women, not after radiation therapy ü Easier if multiple and bilateral : Background enhancement
Ø Birads2 if : ü < 5 mm, ü No associated findings ü Not menopausal women, not after radiation therapy ü Easier if multiple and bilateral : Background enhancement
Ø Birads3 if ü 1st MRI in BRACx women ü Post menopausal or post radiation therapy ü Unique or few or in not glandular zone of breast. ü Breast cancer or Birads 5 Lesion in contralateral breast Follow up : 3/4 months, 6/8 months, 12 months
Foci or UBO (unidentify bright object)
Ø Birads2 if : ü < 5 mm, ü No associated findings ü Not menopausal women, not after radiation therapy ü Easier if multiple and bilateral : Background enhancement
Ø Birads3 if ü 1st MRI in BRACx women ü Post menopausal or post radiation therapy ü Unique or few or in not glandular zone of breast. ü Breast cancer or Birads 5 Lesion in contralateral breast Follow up : 3/4 months, 6/8 months, 12 months
Ø Birads 4 Lesion Birads 5 or 6 in same breast = biopsy PPV of cancer : 3 à 95% If < 4mm : PPV of biopsy : 0 ; If > 4 mm : PPV of biopsy 20-30%
Foci or UBO (unidentify bright object)
3 lesion types : Ø Foci Ø Masses : MARGIN Ø Non-Mass Enhancement
Conclusion:BiRads 0? 2? 3? 4? 5 ?
RNM
Ø 2003-2005 : 1523 MRI / 1128 p Ø 258 L BiRads 4,5 – 196 p : 186 LB, 72 Cancers (21 DCIS, 34 DIC
11 LIC, 6 others) Ø 95 NME
ü 27 M ü 68 B
NME
NME
Ø 2008-2009 : 131 NME / 115 p – Breast cancer 46, HR 29, PS 40 Ø 63 BL, 12 FL, 56 Cancers
NME symmetric, focal, bilateral : BiRads 2
NME, asymmetric : not so easy
NME, asymmetric : not so easy
Radiation therapy of the Left B 5 years ago … BiRads2
49 y-o, BRCA2, first MRI ACR4 : DCIS
NME
2mn 6mn
T2 T1
4/5
4/5 4/5
4/5 4/5
3
4/5 4/5
4/5 4/5
131 L 31 Birads 3 : 1 C 100 BiRads 4/5 : 56 C ou FL FP : 74/131 (55%)
2nd look US - Biopsies
Ø Visibility : Masses 57- 62%, NME 12-31 %
2nd look US - Biopsies
Ø Visibility : Masses 57- 62%, NME 12-31 % Ø PPV of K if lesions seen on 2nd look US or not
ü Demartini, 2009 : (167) 36% - 22% ü Abe, 2010 : (202) 29% - 13% If MRI + and US - : 13 à 35% K à Biopsy always ++
2nd look US - Biopsies
Ø Visibility : Masses 57- 62%, NME 12-31 % Ø PPV of K if lesions seen on 2nd look US or not
ü Demartini, 2009 : (167) 36% - 22% ü Abe, 2010 : (202) 29% - 13% If MRI + and US - : 13 à 35% K à Biopsy always ++
Ø Meissniger, 2009 : Corrélation MRI / US : 519 ü 56% ok : 62% if masses – 31% if NME ü 80 US Biopsy for BL 10 lesions not same on MRI and US : 9 cancers
Thomassin et al. Breast Cancer Res Treat. 2012 A plea for the biopsy marker: how, why and why not clipping after breast biopsy?
Ø Safe : No toxicity (gadolinium-chelates)
Ø High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease
Ø Good reproducibility : Inter et Intra observers
Ø Low coast : Money, Medical’s and Patient’s time
Ø Easy comparison with gold standards ü Biopsy ü Surgery ü Histopathology
The breast MRI we need
The breast MRI we dream
Ø No contra indications
Ø Suppine position likes US, Surgery and radiotherapy
Ø No contrast need
Ø Few sequences to characterize (without doubts) ü Lesions ü Treatment response
Ø Uncertainties of radiological analysis easy to explain to referent collegues and patients …
(with color and arrows to help them to find target – may be a need for radiologist also)
ü ECR 2013 : B- 0325 = Meilleure délimitation pour le boost de radiothérapie
SUPPINE POSITION
Real-time US Pre-contrast T1WI
Early phase T1WI Late phase T1WI
SUPPINE POSITION Nakano et al. Breast Cancer Research and Treatment 2012 ü 196 patients MRI in suppine position. 67 lesions in 55p. ü 24M, 43B ü 2nd look sonogrphy : real-time virtual sonography
ü B- 0453 = FSET2 ideal + Diff (3T, 31 cas) No contrast needed for response assessment after
neoadjuvant Chemotherapy
ü B- 0954 = Multi spectral sequences with T1 and T2 cartography § 46 lesions (18 B, 28 M) § Ratio T1/T2 élevé dans K
ECR 2013 : No contrast
Key points
1. Respect indications 2. Respect technical conditions 3. Use BiRads lexicon (allowed Birads 0) 4. 3T, Contrast-media, DWI-MRI helpfull
No more problems after MRI than before ü Explain it to referent collegues ü Explain it to patients Before to perform Breast MRI
Thank you