Breast MRI and MRI Breast MRI and MRI- guided guided Breast Biopsy Breast Biopsy R. Edward R. Edward Hendrick Hendrick, PhD, FAAPM, FACR , PhD, FAAPM, FACR Lynn Sage Comprehensive Breast Center Lynn Sage Comprehensive Breast Center Northwestern University Medical School Northwestern University Medical School Chicago, Illinois Chicago, Illinois Clinical Indications for Contrast Clinical Indications for Contrast- enhanced Breast MRI: enhanced Breast 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 • 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 Clinical Indications for Contrast Clinical Indications for Contrast- enhanced Breast MRI: enhanced Breast MRI: Technical Requirements Technical Requirements For Good Cancer Detection: For Good Cancer Detection: • High High- field breast MRI (1.5T or >) field breast MRI (1.5T or >) • Gadolinium Gadolinium- DTPA injection DTPA injection • Dedicated bilateral breast coil Dedicated bilateral breast coil • Good fat suppression techniques Good fat suppression techniques • High High- resolution 3D gradient echo resolution 3D gradient echo pulse sequence pulse sequence Technical Requirements Technical Requirements For Good Cancer Detection: For Good Cancer Detection: • High High- resolution 3D gradient echo resolution 3D gradient echo pulse sequence pulse sequence – Bilateral coverage Bilateral coverage – In In- plane resolution < 1 mm plane resolution < 1 mm – Slice thicknesses < 3 mm Slice thicknesses < 3 mm • Dynamic imaging with adequate Dynamic imaging with adequate temporal resolution (1 temporal resolution (1- 2 minutes) 2 minutes) T1W T1W- Gradient Gradient- echo Pre echo Pre- Gd Gd- chelate chelate Why Why Gd Gd- chelates chelates Are Are Essential Essential for Cancer Detection for Cancer Detection T1W T1W –Gradient Gradient- echo echo 2 minute Post 2 minute Post Gd Gd
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Breast MRI and MRIBreast MRI and MRI--guided guided Breast BiopsyBreast Biopsy
R. Edward R. Edward HendrickHendrick, PhD, FAAPM, FACR, PhD, FAAPM, FACRLynn Sage Comprehensive Breast CenterLynn Sage Comprehensive Breast CenterNorthwestern University Medical School Northwestern University Medical School
Chicago, IllinoisChicago, Illinois
Clinical Indications for ContrastClinical Indications for Contrast--enhanced Breast MRI:enhanced Breast 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
• 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
Clinical Indications for ContrastClinical Indications for Contrast--enhanced Breast MRI:enhanced Breast MRI:
Technical RequirementsTechnical RequirementsFor Good Cancer Detection:For Good Cancer Detection:
•• HighHigh--field breast MRI (1.5T or >)field breast MRI (1.5T or >)•• GadoliniumGadolinium--DTPA injectionDTPA injection•• Dedicated bilateral breast coilDedicated bilateral breast coil•• Good fat suppression techniquesGood fat suppression techniques•• HighHigh--resolution 3D gradient echo resolution 3D gradient echo
pulse sequencepulse sequence
Technical RequirementsTechnical RequirementsFor Good Cancer Detection:For Good Cancer Detection:•• HighHigh--resolution 3D gradient echo resolution 3D gradient echo
Why Why GdGd--chelateschelates Are Are EssentialEssentialfor Cancer Detectionfor Cancer Detection
T1W T1W ––GradientGradient--echoecho2 minute Post 2 minute Post GdGd
SagittalSagittalMaximum Maximum Intensity Intensity Projection Projection (MIP)(MIP)
Siemens 2Siemens 2--channel Bilateral Breast Coil channel Bilateral Breast Coil Why Use a Dedicated Breast Coil?Why Use a Dedicated Breast Coil?Same STIR Pulse Sequence at 1.5TSame STIR Pulse Sequence at 1.5T
44--Channel Breast Coil Body Coil as ReceiverChannel Breast Coil Body Coil as Receiver
SNR = 190 SNR = 27
PrePre--ContrastContrast
3D T1W Scans without Fat Saturation
PostPost--ContrastContrast
Why Use FatWhy Use Fat--saturation in Contrast Series?saturation in Contrast Series?
1st Post-Contrast Subtracted Image
Residual Signal Due to Motion Residual Signal Due to Motion Between PreBetween Pre-- and Postand Post--Contrast Images Mimics Contrast Images Mimics EnhancementEnhancement
Examples of Bad and Good Examples of Bad and Good Image QualityImage Quality
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
T2T2--FSE FSE or TSEor TSE
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
PrePre--GdGd
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
11stst
PostPost--GdGd
LargerLarger FOV than NecessaryFOV than Necessary
Low Matrix for Bilateral Axial ScanLow Matrix for Bilateral Axial Scan
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
10 Ways to Tell That a Site Isn10 Ways to Tell That a Site Isn’’t Doing t Doing Good Breast MRIGood Breast MRI
•• Field strength < 1.5 TField strength < 1.5 T•• Images acquired unilaterally onlyImages acquired unilaterally only•• No fat saturation in CE imagesNo fat saturation in CE images•• Inadequate Inadequate GdGd--DTPA uptakeDTPA uptake•• InIn--plane resolution > 1 mm in CE imagesplane resolution > 1 mm in CE images•• Slice thickness > 3 mm in CE imagesSlice thickness > 3 mm in CE images•• No dynamic information obtainedNo dynamic information obtained•• Images interpreted from filmImages interpreted from film•• BIRADS for breast MRI not usedBIRADS for breast MRI not used•• Few or no vessels seen on 3D Few or no vessels seen on 3D MIPsMIPs
Looking at 3D Looking at 3D MIPsMIPs in the Acquired in the Acquired Projection Plane is a Good Way to Projection Plane is a Good Way to
•• MRIMRI--guided breast biopsy is guided breast biopsy is appropriate for suspicious enhancing appropriate for suspicious enhancing lesions seen on MRI and not seen on lesions seen on MRI and not seen on mammography or breast USmammography or breast US
•• Breast MRI has an important role in Breast MRI has an important role in the search for and evaluation of breast the search for and evaluation of breast cancer cancer
ConclusionsConclusions
•• MRIMRI--guided breast biopsy usually gets guided breast biopsy usually gets sufficient samples, but can sufficient samples, but can underestimate diseaseunderestimate disease
•• It is harder to confirm correct sampling It is harder to confirm correct sampling with MRIwith MRI--guided breast biopsy than guided breast biopsy than with xwith x--ray or US guidanceray or US guidance