Breast MRI

1
Breast MRI The Future of Breast
ImagingKenneth H Harris,MDDirector of Breast
ImagingLehigh Valley hospitalAllentown, PA
2
IMAGING OF THE KNEE
3
IMAGING OF THE KNEE

• Hes joking

4
IMAGING OF THE KNEE

• Hes joking
• O.K.Hes not joking

5
Mass on back of knee

• Xray
• MRI
• Nuclear Medicine Scan
• Ultrasound of Popliteal Vein
• Ultrasound of Popliteal Artery
• MRA, CTA
• These tests are all nearly 100 sensitive

6
Knee Breast

• Mammogram (85 sens)
• Mammogram (50 sensitive in dense breasts)
• Ultrasound

• Xray
• CT scan
• MRI
• Nuclear Medicine Scan
• Ultrasound of Popliteal Vein
• Ultrasound of Popliteal Artery
• MRA, CTA

7

• Number of people who die each year from fatal
  disease of the knee ? 0
• Number of people who die each year from breast
  cancer 40,000

8
Breast MRI The Future of Breast
ImagingKenneth H Harris,MDDirector of
Breast imagingLehigh Valley HospitalAllentown,
PA
9
Topics

• Overview where we have come from
• Breast MRI the good
• Breast MRI the bad
• Breast MRI - the rest of the story
• Brief Quiz/game
• Future technologies PEM, BSGI, Tomosynthesis

10
A Very Brief History of Breast
Imaging1950-2007 and beyond
11
From One Ozzie to Another
12
Timeline of Breast Diagnosis

• 1950s Breast Self Examination

13
Timeline of Breast Diagnosis

• 1950s Breast Self Examination
• 1960s BSE Mammography

14
Timeline of Breast Diagnosis

• 1950s Breast Self Examination
• 1960s BSE Mammography
• 1970s BSE Mammography
  Thermography Ultrasound

15
Timeline of Breast Diagnosis

• 1950s Breast Self Examination
• 1960s BSE Mammography
• 1970s BSE Mammography Thermography
  Ultrasound
• 1980s BSE mammography Better US
• 1990s BSE mammo US MRI
• 2000s Digital mammo US MRI

16

• Who stole the monthly Breast self
  examination????????????????

17
American Cancer Society

• Breast awareness and breast self-exam (BSE) BSE
  is an option for women starting in their 20s.
  Women should be told about the benefits and
  limitations of BSE. Women should report any
  changes in how their breasts look or feel to
  their health professional right away.
• If you decide to do BSE, you should have your
  doctor or nurse check your method to make sure
  you are doing it right. If you do BSE on a
  regular basis, you get to know how your breasts
  normally look and feel. Then you can more easily
  notice changes. But its OK not to do BSE or not
  to do it on a fixed schedule.

18
Timeline of Breast Diagnosis

• 1950s Breast Self Examination
• 1960s BSE Mammography
• 1970s BSE Mammography Thermography
  Ultrasound
• 1980s BSE mammography Better US
• 1990s BSE mammo US MRI
• 2000s Digital mammo US MRI
• 2010?? Digital mammo US MRI Tomosynthesis
  PEM BSGI

19
DIGITAL MAMMOGRAPHY

• DENSE BREASTS
• WOMEN UNDER 50
• PREMENOPAUSAL WOMEN
• EQUAL OR SLIGHTLY REDUCED RADIATION DOSE

20
Breast Ultrasound

• Not a screening test
• Good for lumps
• Good for clarification of abnormalities seen on
  mammography other than calcifications

21
Definitions

• Sensitivity divide the number of cancers
  diagnosed by the number of cancers actually
  present
• True positives lesions called positive that
  prove to be cancer

22
Sensitivity/Specificity

• Mammography
• 85-90 sensitive
• (can be as low as 50 in women
  with very dense breasts)
• 25-30 True positives i.e. we recommend 4
  biopsies to find one cancer

23
Sensitivity/Specificity

• Breast MRI
• DCIS 80-90
• Invasive cancer
• sensitivity gt 97
• True Positives 60-90

24
Indications of Breast MRI

• Based on guidelines established by the American
  College of Radiology

25
Indications of Breast MRI

• Based on guidelines established by the American
  College of Radiology
• Staging newly diagnosed breast carcinoma

26
Indications

• Staging newly diagnosed breast carcinoma
• Additional lesions on same breast
• Unsuspected lesions in opposite breast(5)
• Axillary lymph nodes
• Better estimate of tumor size than mammography
• Better to see invasion of chest wall muscle

27
Indications of MRI

• Staging newly diagnosed breast carcinoma
• Unknown causes of axillary adenopathy

28
Indications of MRI

• Staging newly diagnosed breast carcinoma
• Unknown causes of axillary adenopathy
• Neoadjuvant chemotherapy

29
Indications of MRI

• Staging newly diagnosed breast carcinoma
• Unknown causes of axillary adenopathy
• Neoadjuvant chemotherapy
• Silicone implant rupture

30
Indications of MRI

• Staging newly diagnosed breast carcinoma
• Unknown causes of axillary adenopathy
• Neoadjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients

31
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)

32
New ACS Guidelines

• Insufficient evidence to suggest for or against
  yearly MRI for people with personal history of
  breast cancer
• Dense Breasts
• LCIS, ADH

33
Examples of ACS Study

• Netherlands study
• 1909 high risk patients
• 50 cancers
• 80 detected by MRI
• 33 detected by mammography

34
Examples of ACS study

• UK
• 649 high risk women
• 35 cancers
• MRI found 77
• Mammography found 40

35
Examples of ACS Study

• Canada
• 236 Women at high risk
• 22 cancers
• MRI found 77
• Mammo found 36

36
Examples of ACS Study

• Bonn
• 529 Women at high risk
• 43 cancers
• MRI found 91
• Mammography found 33

37

• 76 of all women diagnosed with breast cancer
  have no risk factors

38
Why not screen everybody?????

• Hey, a normal MRI virtually excludes invasive
  breast cancer!

39
Definition of screening test

• The test must be
• Readily available
• Sensitive
• Specific
• Cheap
• Safe

40
(No Transcript)
41
(No Transcript)
42
Indications

• Staging newly diagnosed breast carcinoma
• Unknown causes of axillary adenopathy
• Neoadjuvant chemotherapy
• Silicone implant rupture
• Screening high risk patients
• Difficult mammogram/ultrasound/physical
  examination

43
Disadvantages of MRI

• Positive Predictive Value
• Cost
• Microcalcifications
• Cancers lt 3 mm
• 30 minutes on magnet motion, sedation?

44
Examples of Breast MRI Images
45
DCIS
46
Cancer
47
(No Transcript)
48
(No Transcript)
49
31 yo small palpable mass
50
31 yo small palpable mass
51
right
60 y o with known dx Left breast caner. Neg mammo
52
69 y.o. neg mammo large l axillary nodes
53
64 y . 12 days post lumpectomy with margins
54

• Patient with known diffuse infiltrative cancer in
  left breast with findings in opposite breast on
  staging MRI

55
(No Transcript)
56
42 yo-prior and after chemotherapy ideal for
breast conservation
57
67 y o tumor fragmenting after chemotx same
overall size bad for breast conservation
58
TRUE OR FALSE
59
True or False ??????
60
(No Transcript)
61
Deal or no deal
62
Scenario 1

• Good news. Although I have a mass in my breast,
  my mammogram was normal.
• That means I dont have breast cancer

63
Deal or no deal
64
Scenario 2

• Great news! Although I had a lump in my breast,
  my mammogram and ultrasound were both normal.
  Hat means I dont have breast cancer.

65
Deal or no deal
66
Scenario 3

• Wonderful news! Although I have a lump in my
  breast, I had a breast MRI and it ws normal.
  That means I dont have breast cancer

67
Scenario 4

• Spectacular news. Although I have a lump in my
  breast, my MRI and mammogram and ultrasound were
  all normal. That means I dont have breast
  cancer

68
Deal or no deal
69
Scenario 5

• Digital mammography is better than the older
  analog technique

70
Deal or no deal
71
Scenario 6

• I cant stand having my breasts compressed every
  year. Im just going to have a screening
  ultrasound study

72
Deal or no deal
73
Scenario 7

• My mom had breast cancer. That means I should
  be getting a yearly MRI instead of a mammogram

74
Deal or no deal
75
Scenario 8

• No one in my family has had breast cancer. That
  means my chances of getting it are pretty small

76
(No Transcript)
77
Deal or no deal
78
Future technologies

• PEM
• BSGI
• Digital Tomosynthesis

79
PEM Scanning

• Positron Emmision Mammography
• A PEM scanner answers the question
• What would happen if a mammogram machine married
  a PET scanner and had a baby?

80
(No Transcript)
81
PEM Examples
82
Tomographic Display
2mm Resolution
83
Surgical Planning
Multifocality/Multicentricity
Unsuspected 2nd Lesion
X-Ray
PEM
84
Surgical Planning Bilateral Disease
Unsuspected Contralateral Lesion
X-Ray
PEM
85
Occult Cancer
8 months later high resolution PET scan with
compression shows intense focus (4-mm invasive
ductal carcinoma)
X-ray guided core biopsy showed no cancer
86
Dense Breast
Superior
RCC
RMLO
X-Ray
Inferior
PEM
87
The Breast Journal Published July 2006
Berg et al. The Breast Journal 12(4)309-323,
2006
88
BSGI

• Breast
• Specific
• Gamma
• Imaging

89
Examples of BSGI
90
(No Transcript)
91
Digital Tomosynthesis

• Examples

92
(No Transcript)
93

• Thank you