Developments in Breast Developments in Breast Imaging: In Memory of Imaging: In Memory of Dr. Carolyn Dr. Carolyn Kimme Kimme- Smith Smith Enhancement Characteristics Enhancement Characteristics of Cancer on Breast MRI and of Cancer on Breast MRI and Biopsy Techniques Biopsy Techniques Debra M. Ikeda, M.D. Debra M. Ikeda, M.D. Director of Breast Imaging Director of Breast Imaging Professor of Radiology Professor of Radiology Stanford University, Stanford, CA Stanford University, Stanford, CA Image courtesy of Bruce L. Daniel, M.D. Image courtesy of Bruce L. Daniel, M.D. Debra M. Ikeda, M.D. Debra M. Ikeda, M.D. Director of Breast Imaging Director of Breast Imaging Professor of Radiology Professor of Radiology Stanford University, Stanford, CA Stanford University, Stanford, CA Image courtesy of Bruce L. Daniel, M.D. Image courtesy of Bruce L. Daniel, M.D. • Images courtesy of American College of Radiology ACR BI Images courtesy of American College of Radiology ACR BI-RADS MRI, in RADS MRI, in American College of Radiology BI American College of Radiology BI-RADS Imaging Atlas, Reston, VA, 2003, RADS Imaging Atlas, Reston, VA, 2003, ACR Breast MRI Lexicon Committee, International Working Group on ACR Breast MRI Lexicon Committee, International Working Group on breast breast MRI, Bruce L. Daniel, M.D., MRI, Bruce L. Daniel, M.D., Sunita Sunita Pal, M.D. and Pal, M.D. and Aya Aya Kamaya, M.D. Kamaya, M.D. Open Breast Coil Open Breast Coil MRI Devices 4-coil phased array
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Developments in Breast Developments in Breast Imaging: In Memory of Imaging: In Memory of
Dr. Carolyn Dr. Carolyn KimmeKimme--SmithSmithEnhancement Characteristics Enhancement Characteristics of Cancer on Breast MRI and of Cancer on Breast MRI and
Biopsy TechniquesBiopsy TechniquesDebra M. Ikeda, M.D.Debra M. Ikeda, M.D.
Director of Breast ImagingDirector of Breast ImagingProfessor of RadiologyProfessor of Radiology
Stanford University, Stanford, CAStanford University, Stanford, CAImage courtesy of Bruce L. Daniel, M.D.Image courtesy of Bruce L. Daniel, M.D.
Debra M. Ikeda, M.D.Debra M. Ikeda, M.D.Director of Breast ImagingDirector of Breast Imaging
Professor of RadiologyProfessor of RadiologyStanford University, Stanford, CAStanford University, Stanford, CA
Image courtesy of Bruce L. Daniel, M.D.Image courtesy of Bruce L. Daniel, M.D.
•• Images courtesy of American College of Radiology ACR BIImages courtesy of American College of Radiology ACR BI--RADS MRI, in RADS MRI, in American College of Radiology BIAmerican College of Radiology BI--RADS Imaging Atlas, Reston, VA, 2003, RADS Imaging Atlas, Reston, VA, 2003, ACR Breast MRI Lexicon Committee, International Working Group onACR Breast MRI Lexicon Committee, International Working Group on breast breast MRI, Bruce L. Daniel, M.D., MRI, Bruce L. Daniel, M.D., SunitaSunita Pal, M.D. and Pal, M.D. and AyaAya Kamaya, M.D.Kamaya, M.D.
Image courtesy of Bruce L. Daniel, M.D.Image courtesy of Bruce L. Daniel, M.D.
Breast MRI and MRIBreast MRI and MRI--BxBx
What is actually happening in US clinical practice?
What is breast MRI standard of care?
What are the new BIRADS MRI recommendations for 2010 ACR Atlas?
What are MRI breast biopsy results?
2008 National MRI Trends2008 National MRI TrendsBassett et al. AJRBassett et al. AJR
74% of practices offer MRI (557/754)
62% 5 MRI/wk (n=354), 10% >20/wk (n=54)
31.7% do no MRI Bx (n=173)
64% do screening MRI (n=359)
All soft copy read, 50% with CAD
48% never/29% rarely read outside MRIs
47% never/38% rarely read MRI w/o mammo/US
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UnilateralBilateral
Diagnostic Breast MRIUtilization at Stanford
MRI/MRI Biopsy Volumes*MRI/MRI Biopsy Volumes*MRI MRI BX TOTAL
2001 335 61 396
2002 827 105 932
2003 1120 172 1320
2004 1150 170 1320
2005 1120 172 1292
2006 1231 211 1442
Breast MRI and MRIBreast MRI and MRI--BxBx
What is breast MRI standard of care?
GadoliniumGadolinium--EnhancementEnhancement
Tumor AngiogenesisTumor Angiogenesis
Image courtesy Bruce L. Daniel MDImage courtesy Bruce L. Daniel MD
The Current Status of Breast MR The Current Status of Breast MR Imaging (Part 1 of 2 parts)Imaging (Part 1 of 2 parts)1. Spatial and temporal resolution are
important2. Understand perfusion and capilllary
leakage, tissue T1 and T2 relaxation3. Most sensitive for cancer; MRI and
Mammo offer complementary information
*Christiane Kuhl, M.D. Radiology 2007, August Vol 244; 2; 356-378 and Radiology 2007, September Vol 244; 3; 672-691
The Current Status of Breast MR The Current Status of Breast MR Imaging (Part 1 of 2 parts)Imaging (Part 1 of 2 parts)4. Specificity and PPV for MRI are
equivalent to Mammo5. Work-up for MRI findings are more
demanding than mammo or US, improvements for MRI are in great demand
6. Advances have been made in MRI interpretation guidelines
7. MRI biopsy is necessary*Christiane Kuhl, M.D. Radiology 2007,
August Vol 244; 2; 356-378
The Current Status of Breast MR The Current Status of Breast MR Imaging (Part 2)Imaging (Part 2)1. Clinical applications for MRI include
A. Problem Solving for equivocal mammo or US findings
B. MRI Biopsy necessary 40% US unseen C. Neoadjuvant chemotherapyD. Avoid over-treatment of MRI findings
Use MRI findings wisely - it is wrong totransfer mammo guidelines to MRI
E. High Risk screening
*Christiane Kuhl, M.D. Radiology 2007, September Vol 244; 3; 672-691
Screening ReferenceScreening Reference• Saslow D, Boetes C, Burke W, et al. American
Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA Cancer J Clin. 2007;57:75-89
MRI Breast Cancer ScreeningMRI Breast Cancer ScreeningAUTHOR YEAR #WOMEN #CANCERS %
KUHL 2000 192 HIGH RISK 9 4.6%
TILANUS-LINTHORP 2000 109 HIGH RISK 3 (6FP) 2.8%
WARNER 2001 196 BRCA1/2 7 3.6%
STOUTJESDIJK 2001 179 HIGH RISK13 (MRI ONLY) 7.3%
MORRIS 2003 367 HIGH RISK 14 (50 FP) 4%
LEE 2003182 (CA OPPOSITE)
7/ (8FP) 3.8%
HARTMAN 2004 41 HIGH RISK 1 2.4%
WARNER 2004 236 BRCA1/2 17/22 7.2%
KRIEGE 2004,06 1909 HIGH RISK 32/45 1.6%
LEHMAN 2005 367 HIGH RISK 4 (19FP,5%) 1.1%
MRI Breast Cancer ScreeningMRI Breast Cancer ScreeningAUTHOR YEAR #WOMEN #CANCERS %
PORT 2007 182 LCIS/ATYPIA 5 3%
TRECATE 2006 116 HIGH RISK 10 10%
LEHMAN 2007 171 HIGH RISK 6 3.5%
PEDICONI 2007118 CONTALATERAL OR HIGH RISK
22 5.3%
PORT 2007 182 LCIS/ATYPIA 5 3%
MRI Breast Cancer OppositeMRI Breast Cancer OppositeBreastBreast
AUTHOR YEAR #WOMEN #CANCERS %
RIEBEL 1998 34 3 11%
FISCHER 1999 463 19 4%
KUHL 2000 710 45 6%
SLANETZ 2002 17 4 24%
LIBERMAN 2002 223 12 5%
LEE 2003 182 7/ (8FP) 4%
VIEHWEG 2003 119 4 4%
LEHMAN 2007 969 30 3.1%
Breast MRI and MRIBreast MRI and MRI--BxBx
What are the new BIRADS MRI recommendations for 2010 ACR Atlas?
International Working Group for International Working Group for Breast MRIBreast MRI
and and American College of RadiologyAmerican College of RadiologyBreast MRI Lexicon CommitteeBreast MRI Lexicon Committee
19981998--20032003
ACR BIACR BI--RADS RADS -- MRIMRIImaging Atlas, Reston, VA 2003Imaging Atlas, Reston, VA 2003
2006/09 2006/09 Updates for ACR BIUpdates for ACR BI--RADSRADS™™1. Do bilateral studies2. Describe background enhancement3. Do T2-weighted non-contrast exams4. Check Kinetics5. Facilities doing breast MRI should be
able to do MRI-guided biopsy*6. Do combined reporting(MRI Screening advised for 20-25% lifetime risk
and women treated for Hodgkin disease**)*Christiane Kuhl, M.D. Radiology 2007, September
Vol 244; 3; 672-691 **Saslow D et al. Ca Cancer J Clin 2007; 57 (2) 75-
78
2006 Improvements for 2006 Improvements for ACR BIACR BI--RADSRADS™™
1. Do bilateral studies**
Easier to compare symmetry ofbackground enhancement pattern
chemotherapy, comparing response and surgical management before/post MRI
16 successful breast conservation
14 mastectomies
MRI would have helped therapy in 6 (20%) 5 mastectomy avoid chemotherapy,1 would avoid unsuccessful conservation
MRI would hinder therapy in 3: not prevent unsuccessful conservation (1) or prevent successful conservation (3)
Thibault F et al. AJR 2004; 183:1159-68
NonNon--Spic (CR) preSpic (CR) pre-- chemochemo
NonNon--Spic (CR) postSpic (CR) post--chemochemo ChemotherapyChemotherapyPre Post Pre Post
Images courtesy of Dr. Bruce L. DanielImages courtesy of Dr. Bruce L. Daniel
T2T2--weighted images*weighted images*Fluid (cysts) bright against fat
Normal fluid in ducts
Lymph nodes (UOQ, vessel,fat)
Cellular FA (bright, sclerotic dark)
Lactating patients bright glands, cancers dark
Breast edema
Beware mucinous cancers (pitfall)** Kuhl CK et al JMRI 1999; 9: 187-96, Yuen et al. JMRI 2007;25:502-10,
Espinosa et al. Radiology 2005;237:249-36
Breast CA with High Signal Breast CA with High Signal Intensity on T2Intensity on T2--weighted Imagesweighted Images30/480 breast cancers had high T2-weighted SI (8 mucinous; 22 nonmucinous cancers) compared 19 FA
Hi SNR and enhancing septations in mucinous cancers and irregular border, no dark septations and rim enhancement in non-mucinous cancers separated them from FA
Yuen et al JRMI 2007;25;502-10
Case 2007Case 2007-- UK4UK4
T2 FSE Fat SatT2 FSE Fat Sat T1 3D SPGR Fat T1 3D SPGR Fat Sat Sat -- Post GadPost Gad
T1 Spiral 10 seconds after Gd arrival in Breast
Images courtesy of Bruce L. Daniel, M.D.Images courtesy of Bruce L. Daniel, M.D.
What are TP biopsy rates for What are TP biopsy rates for MRI?MRI?
Current MRI sequences/hardware make high resolution/kinetic scans now more available
Several vendors offer CAD, dedicated breast coils, MRI-compatible grids, needles and vacuum assisted biopsy probes
MRI-guided pre-operative needle localization and vacuum assisted core availability increasing
Reported TP biopsy rates comparable to mammography
Right Breast in Left CoilRight Breast in Left Coil
Courtesy Bruce Daniel, MDCourtesy Bruce Daniel, MD
4-Coil Phased-ArrayOpen Platform Breast Coil, MRI-Devices Inc,Waukesha, WI
MRI Breast Lesion Marking System, E-Z-EM Inc., Westbury, NY