1. Recent advances in MRI Breast and Future
Dr.Rattehalli R Ramachandra
Consultant Radiologist
University Hospitals Coventry & Warwick NHS trust

2. Introduction Timeline of Breast diagnosis Role of MRI Breast
Recent advances
Other modalities
Conclusion

3. Breast cancer UK Commonest cancer in women
Accounts for 31% of all cancers in women
Life time risk for men in 1014
Life time risk for women 1 in 9
Ref: Cancer research UK Feb 2009

4. Timeline of Breast Diagnosis
1950’s – Breast Self Examination
1960’s – BSE + Mammography
1970’s – BSE + Mammography + Thermography+ Ultrasound
1980’s – BSE + mammography + Better US
1990’s – BSE + mammo + US + MRI
2000’s – Digital mammo + US + MRI
2010?? – Digital mammo + US + MRI + MR spectroscopy+Tomosynthesis + PEM + BSGI

5. Spiculate mass left Breast

6. Right Breast Screening Mammogram
Recalled from screening

7. Coned view

8. US Bx Invasive lobular cancer

9. Any more lesions ?

10. MRI Breast with contrast

11. MRI Breast with contrast and subtraction

12. Colour mapping

13. MRI Breast 2006 to 2010 April

14. Timeline of Breast Diagnosis
1950’s – Breast Self Examination
1960’s – BSE + Mammography
1970’s – BSE + Mammography + Thermography+ Ultrasound
1980’s – BSE + mammography + Better US
1990’s – BSE + mammo + US + MRI
2000’s – Digital mammo + US + MRI
2010?? – Digital mammo + US + MRI + Tomosynthesis + PEM + BSGI

15. Sensitivity & Specificity Mammogram Vs Ultrasound Vs MRI
81.85%
99%
Ultrasound
86.4%
98.1%
MRI 3T
100%
93.9%
Reference: Haitham Elsamaloty et al . AJR 2009; 192: , Increasing the accuracy of detection of Breast Cancer with 3-T MRI.

16. PPV of Mammography for Breast cancer
For under 50 yrs ranges from 20%
For age yrs 60-80%

17. Sensitivity and Specificity of Annual MRI, Mammography, Ultrasound and 6 Monthly CBE in High Risk Women
AUTHOR
MAMMOGRAPHY
ULTRASOUND
MRI
CBE
SENSITIVIT Y (%)
SPECIFICIT Y (%)
SENSITIVI TY (%)
SPECIFICI TY (%)
Kuhl et al 33 98 80
100 95 NS
Tilanus- Linthorst et al -
Stoutjesdij k et al 42 96 89
Podo et al 13 99
Morris et al 69 77
Kriege et al 40 71 90 18
Warner et al 36 9
Cancer Imaging 2005; 5(1): 32-38

18. MR Vs Mammogram Examples
Netherlands study
1909 high risk patients
50 cancers
80% detected by MRI
33% detected by mammography

19. MR Vs Mammogram ExamplesUK
649 high risk women
35 cancers
MRI found 77%
Mammography found 40%

20. MR Vs Mammogram Examples
Canada
236 Women at high risk
22 cancers
MRI found 77%
Mammo found 36%

21. MR Vs Mammogram Examples
Bonn
529 Women at high risk
43 cancers
MRI found 91%
Mammography found 33%

22. Breast Ultrasound Not a screening test Good for lumps
Good for clarification of abnormalities seen on mammography other than calcifications
Good for taking biopsies

23. DIGITAL MAMMOGRAPHY DENSE BREASTS WOMEN UNDER 50 PREMENOPAUSAL WOMEN
EQUAL OR SLIGHTLY REDUCED RADIATION DOSE
Coventry is now fully digital
Digital Tomosynthesis reduces the recall rate in dense breasts

24. Indications Staging newly diagnosed breast carcinoma ?
Lobular cancer staging
Unknown causes of axillary adenopathy
Neo adjuvant chemotherapy
Silicone implant rupture
Screening high risk patients
Radiation exposure at young age
Difficult mammogram/ultrasound/physical examination, Problem solving

25. COMICE Trial Results Between 2001 to 2007
1625 patients,817 with 807 without MRI
Re operation with in 6 months was
18.8% with MRI & 19.3% without MRI
Result: No significant benefit by addition of MRI to conventional Triple assessment
Comparitive effeciveness of MRI in Breast cancer trial
Reference: L.Turnbul,Symposium Mammographicum 2008.Lille, France 06/07/2008, Also Lancet 13/2/2010

26. Indications Staging newly diagnosed breast carcinoma ?
Lobular cancer staging
Unknown causes of axillary adenopathy
Neo adjuvant chemotherapy
Silicone implant rupture
Screening high risk patients
Difficult mammogram/ultrasound/physical examination, Problem solving
Radiation exposure at young age

27. MRI in Invasive Lobular cancer
MRI accurately assesses the size & extent of cancer
Detects cancer on other side
Can change treatment plan in up to 28% of cases
NICE guideline
Example next slide

28. P W 2006 HISTORY 55YRS OLD P 3 R4 LUMP IN RIGHT BREAST
US BIOPSY B5b LOBULAR SINGLE LESION
MRI TO EXCLUDE ANY OTHER LESION
OTHERWISE SUITABLE FOR WLE

29. Multifocal 3 leisons
Patricia Waters 12/10/2006 D19600

30. Indications Staging newly diagnosed breast carcinoma ?
Lobular cancer staging
Unknown causes of axillary adenopathy
Neo adjuvant chemotherapy
Silicone implant rupture
Screening high risk patients
Difficult mammogram/ultrasound/physical examination, Problem solving
Radiation exposure at young age

31. Metastatic Nodes in Axilla With No Obvious Primary in Breast
< 2% of patients present with palpable axillary nodes and negative mammogram and US
MRI finds the primary in up to 60-75% of cases
This should be confirmed by second look US or MR guided biopsy
Examples later

32. Indications Staging newly diagnosed breast carcinoma ?
Lobular cancer staging
Unknown causes of axillary adenopathy
Neo adjuvant chemotherapy
Silicone implant rupture
Screening high risk patients
Difficult mammogram/ultrasound/physical examination, Problem solving
Radiation exposure at young age

33. Extra capsular silicon
B Claire Geraghty 23/11/ /4/2009

34. Silicon only image. Extra capsular silicon with fluid collection

35. Normal side

36. US Extra capsular silicon

37. Extra capsular silicon
B Michelle Wright 15/9/ /4/2009

38. Silicon in Right axillary lymph node

39. Coronal images to asses overall shape

40. Indications Staging newly diagnosed breast carcinoma ?
Lobular cancer staging
Unknown causes of axillary adenopathy
Neo adjuvant chemotherapy
Silicone implant rupture
Screening high risk patients
Radiation exposure at young age
Difficult mammogram/ultrasound/physical examination, Problem solving

41. New ACS Guidelines for Annual MRI Screening in addition to Mammo (May, 2007)
Any woman who has greater than 20% lifetime risk of developing breast cancer
(BRACAPRO, GAIL, BOADACEA)
BRCA mutation and untested relatives
Prior XRT (bet ages of 10-30)

42. NICE Guideline MRI annual surveillance
From yrs:
To women at a 10 year risk >8%
From yrs:
To women at 10 year risk of > 20% or
To women at a 10 year risk of > 12% where mammography has shown a dense breast pattern

43. Radiation exposure at young age
Hodgkin's disease treated with Mantle radiation
Risk of BC increases beginning about 7-8yrs after treatment peaking at about 15yrs post treatment
Younger age at treatment = Higher risk
Many unaware of risk
Begin intensive screening 6-7 yrs after treatment

44. Indications Staging newly diagnosed breast carcinoma ?
Lobular cancer staging
Unknown causes of axillary adenopathy
Neo adjuvant chemotherapy
Silicone implant rupture
Screening high risk patients
Radiation exposure at young age
Difficult mammogram/ultrasound/physical examination, Problem solving

45. Problem solving
Case 1

46. SH 60 yrs. Recalled from screening for possible ASD Right Breast

47. Further views showed normal mammogram.

48. However, US 8mm IDM UOQ Biopsy B5b Invasive DC

49. US localisation for WLE & SNB

50. MDM Specimen X ray normal Breast tissue HP: No tumour in the specimen
SNB positive
Repeat US: Post operative changes only with lot of oedema and seroma. No tumour seen
Decision: To do MRI to try and Identify the tumour

51. MRI Seroma with 23x14mm Tumour

52. MRI Seroma with 23x14 mm Tumour

53. Second look Ultrasound
Guided by MRI location of the lesion
Tumour identified by US and localised again
Tumour excised during ANC
HP report: 22 mm IDC with clear margin

54. Occult on Conventional Imaging
CASE 2
Occult on Conventional Imaging

55. MC 72yrs Clinical: P3 nodularity Left Breast Normal Mammogram
Normal Ultrasound
Clinical core biopsy
HP: Invasive carcinoma mixed Ductal and Lobular
MDM Decision: For MRI to asses exact size
Marion Chapman 72 yrs D32436 55

56. MRI: 53x49mm with axillary nodes 2.3cms56

57. Surgery Mastectomy with axillary node clearance
HP: 50mm Invasive carcinoma mixed Ductal and Lobular Grade 2
3 out of 13 nodes positive for metastases

58. Response to Chemotherapy
Case 3
Response to Chemotherapy

59. 44yr SD H/o LIRB.O/E swelling in right breast with some inflammatory changes.
Susan Daly T88166 59

60. Mammogram: Heterogeneously dense breast Diffuse stromal pattern with no focal mass

61. Ultrasound: Increased vascularity & mixed echogenicity
Ultrasound: Increased vascularity & mixed echogenicity. IDM in UOQ 2cm from right nipple. Axillary nodes up to 3 cm Bx IDC

62. Pre chemo MRI: 80x 43 mm IDM

63. MRI : After 2 courses of Chemotherapy: 6.4x4.5 cm

64. Post Chemotherapy 11wks later: Few tiny enhancing nodules

65. Post operative finding
Four foci of residual grade 2 invasive ductal carcinoma
No realistic tumour size can be estimated

66. CLINICAL AND IMAGING DISCREPANCY
CASE 4
CLINICAL AND IMAGING DISCREPANCY

67. 39 yrs JM H/o Lump in Left Breast O/E 1cm lump in left breast UOQ
Imaging: About 3 cm lump in UOQ
B5b
Suitable for WLE
MDM: For MRI to confirm the size
JILL MIDDLETON P80903 from Warwick 11/9/2008 67

68. MRI : 7 cm IDM and

69. Second lesion found 2cm

70. Dynamic graph typical for cancer

71. Post contrast colour mapping treated by mastectomy

72. Axillary lymphadenopathy

73. LB. 47Yrs. Right axillary nodes
Biopsy: Metastatic carcinoma from Breast
Mammogram: Dense breast. Extensive benign changes with cysts
US: No obvious primary in the Breast

74. Non Contrast T1
Lynnett Barlow 1/4/ AA

75. Non contrast T2

76. Post Contrast Subtraction images

77. Post contrast subtraction

78. LF 51yrs H/o Suspicious lump in left breast Nipple changes Fullness
Ill defined lumpy area inner aspect of left nipple
Leslie Fielding A DOB: 16/7/1958

79. Left Mammogram MLO

80. Coned compression view

81. US: Vague area 20mm. Bx= B1

82. Stereo core Bx = B5b Lobular cancer

83. MDT Patient very reluctant for mastectomy
For MRI to asses the actual size of lesion
Exclude multi focal nature

84. MRI: 60x25mm
MRI 28/10/09

85. Mammoplasty histology
70mm Grade 2 Lobular cancer
Probably multi focal
Difficult to asses size
Lateral margin involved

86. Why not screen everybody?????
Hey, a normal MRI virtually excludes invasive breast cancer!

87. Limitations of MRI False positives:
Overlap of Benign & malignant lesions
Incidental enhancing lesions
About 30%
Needs further assessment with second look US,Bx, ? MR guided

88. False Negatives Invasive lobular cancer
Low grade Ductal cancers eg Tubular
DCIS:
Presents as MC in 73-98%
MRI sensitivity: %
Small lesions < 3mm difficult to detect
Enhancing pattern often atypical
MR spectroscopy may help in future

89. MR spectroscopy 4T
Breast cancer research

90. Inappropriate uses of MRI
Should not be substituted for Mammography or Ultrasound
Should not be used as substitute for a histological diagnosis
No studies proving efficacy of MRI as a screening tool in the general population

91. Conclusion 1 MRI is not a screening tool for women over 50yrs
MRI with Mammogram is good for high risk women
MRI is indicated for staging in invasive lobular cancer
MRI is not required for routine staging
MRI should be used as problem solving tool in difficult circumstances

92. Conclusion 2
We Await new tools like Tomosynthesis, Improved software on Spectroscopy for breast imaging,
Future : CT mammography, BSGI,PEM
MR Ductography

93. Thank you