importance of mri in breast...

THE ROLE OF MR IMAGING IN PATIENTS WITH BREAST CANCER

Nashwa

AbdulsalamAin

Shams University

Gillian Lieberman, MD

Nashwa

AbdulsalamGillian Lieberman, MD

Contents

• Patient presentation• Patient’s imaging work up

• General concepts of MRI

• Indications of MRI

• Contraindications of MRI

• Patient’s MRI

• Patient’s treatment

• Companion patient

• conclusion

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PATIENT PRESENTATION

• A 44 year old female came for a routine screening mammogram

• She has a positive family history of breast cancer in her mother, grandmother and aunt

• No comparison studies. Baseline.

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Patient’s Screening Mammogram

LCC LMLORCC RMLO

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Patient’s screening mammogram showed:

• Numerous areas of microcalcifications

in the central upper outer left breast.

• 1cm irregular, spiculated

mass in the lower inner left breast.

• The right breast was free.• We then performed a diagnostic mammogram for the

patient.

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Patient’s Diagnostic MammogramLCC Mag LLM Mag

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Patient’s diagnostic mammogram showed:

• The breast parenchyma is heterogenously

dense.

• Multiple heterogenously

appearing areas of calcification mainly in the upper outer left breast, with some

calcifications extending below the nipple line.

• The previously described mass does not persist on current imaging.

• The right breast is free• We then performed an US of the areas of calcifications

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Ultrasound of Outer Central Left Breast in Area of Calcifications

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Patients US of the left breast showed:

• At 1 o’clock 7cm from the nipple there is a an irregular hypoechoic

mass that is 1.1x1.4x1.2 cm with multiple

internal echogenic

foci suggesting calcifications

• The upper outer left breast shows an irregular hypoechoic

nodule 0.7x0.8x0.8 cm at 3 o’clock postion

5‐6cm from the nipple with internal echogenic

foci

• Directly adjacent to this structure there is a hypoechoic nodule 0.5x0.5x0.5 cm.

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Core biopsy of the left breast in areas of calcifications showed:

• invasive ductal

carcinoma and ductal

carcinoma in situ

NEXT STEP ???» Surgery» Chemotherapy

» Radiation Therapy» Additional Imaging

MRI

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General concepts• MRI of the breast is an important tool for the detection

of breast cancer, it’s extent and assessment of the silicone implant integrity

• The sensitivity of breast MRI is reported as 71 to 100%

• Its specificity is less than 65%

• Breast MRI images are analyzed for morphology and initial and delayed contrast enhancement. The contrast

used is gadolinium.

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Patterns of uptake of the contrast agent

• It is based on the concept of tumor angiogenesis or neovascularity.

• Tumor associated blood vessels have increased permeability,

• This leads to prompt take up and release of gadolinium within the first one or two minutes after administration

• Leading to pattern of rapid enhancement and washout on MRI

• Thus Benign lesions tend to have a progressive enhancement pattern

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Classification of lesions on MRI• Lesions are categorized into mass or non‐mass lesions.• Mass lesions are assessed for:

1. shape2. margin characteristics3.Enhancement pattern

• Masses with irregular or spiculated

margins, and rapid uptake and rapid washout of gadolinium are worrisome

of malignancy• Non‐mass lesions are characterized by their spatial

distribution and their patterns of enhancement. – Stippled enhancement pattern could be a predictor of

malignancy. – 80% of progressive enhancement pattern are benign

and 20% are malignant.

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Indications

1.Preoperative evaluation of a newly diagnosed breast cancer patient

2. Detection of occult primary breast cancer in women with axillary

metastases

3. Measurement of response to neoadjuvant

chemotherapy

4. Differentiating postoperative change from recurrence

5. Evaluation of inconclusive clinical or imaging findings

6. Screening of high risk women

7. Assessment of Silicone implants

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Preoperative evaluation of a newly diagnosed breast cancer patient:

• MRI is better at detecting the extent of the disease, ipsilateral

and contralateral

disease than

mammography, US or physical examination.

• But due to its low specificity it leads to a lot of unwanted biopsies.

• This would lead to a delay in treatment

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Measurment

of response to neoadjuvent chemotherapy

• This therapy is given to women with locally advanced breast cancer

• The goal of this therapy is to reduce the size of the cancer and allow for breast conservation.

• Response is assessed by physical examination along with breast imaging techniques.

• Change of the size of the lesion on MRI as well as enhancement kinetics correlates with the pathologic

response.

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Differentiating postoperative change from recurrence:

• 10 to 15 % of patients will develop locoregional recurrence within 10 years of treatment with breast

conserving therapy.

• MRI can differentiate surgical scarring and radiation changes from breast cancer

• Enhancement in the prior surgical site is suggestive of recurrence and merits core biopsy

• Absence of enhancement in the biopsy bed suggests fibrosis.

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Evaluation of inconclusive clinical or imaging findings:

• Breast MRI can be used for the evaluation of equivocal findings on conventional imaging with mammography

and US.

• An example of this is focal asymmetry or a mammographic abnormality seen only in one view.

• MRI can also be helpful as an adjunct study to provide guidance for targeted US or core biopsy when

localization is difficult.

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Screening of high risk womenWhich include women with:

1. BRCA mutation or a family history of it

2.High BRCAPRO score:

who have a strong family hitory

with an estimated

lifetime risk of breast cancer greater than 20‐25%

by BRCAPRO score

3.History of chest radiation

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CONTRAINDICATIONS

1.Cardiac pacemakers and other implantable metallic and electronic devices

2.Pregnancy

3.Renal insufficiency

4. Claustrophobia

5. Patient incompatibility with equipment owing to size/body habitus

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Pregnancy

• Decision should be made on individual basis

• Safety of gadolinium contrast not established for pregnant/nursing mothers

• There is increased breast density and rapid diffuse enhancement which interferes with accurate

interpretation

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Renal insufficiency

• Its a late serious adverse effect secondary to use of contrast agent

• There is diffuse symmetrical thickening of the skin of upper and lower extremeties

• Could progress to joint contracture• Can lead to cardiomyopathy, pulmonary fibrosis,

pulmonary hypertension, diaphragmatic paralysis and death

• Gadolinium deposits are found in tissues of patients

• Up to 12% in patients with CKD stage 5 through a single exposure

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Breast MRI In Our Patient

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Breast MRI of our patient showed:

• Post biopsy changes

• Non mass like enhancing lesion in the left breast

• Areas of more confluent enhancement

• The right breast is free

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Breast MRI in Our Patient

Segmental NMLE involving a ductal

unit

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Rapid uptake and rapid wash out of the dye

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Enhancing lesion in the patient’s MRI

TREATMENT

• The patient opted for bilateral mastectomy

• The right breast mastectomy will be done as a prophylaxis as the patient has a positive family history and wants to minimize her future risk of developing a contralateral

cancer

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Companion patient

• 67 year old female with a silicone implant

• Left breast mass was found on US

• MRI showed a 3.5 cm enhancing mass in the posterior outer left breast

• Diagnosis: Primary breast lymphoma

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Companion patient’s US with a mass on top of the silicone implant

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Digital subtraction MRI of companion patient showing enhancing mass in

posterior outer left breast

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MRI of companion patient with contrast enhancement

Diagnosis : primary breast lymphoma

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CONCLUSIONS

• Imaging work‐up for an abnormal finding on screening mammography entails a diagnostic evaluation

• Breast MRI is useful in defining the extent of disease in newly diagnosed cancer patients

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REFERENCES• Heywang

SH, Hahn D, Schmidt H, et al. MR imaging of the breast using adolinium‐

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JM, Nguyen ET, Jaffey

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DP, Gorczyca

SM, Gorczyca

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rupture. Plast

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Surg

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REFERENCES• Martincich

L, Montemurro

F, De Rosa G, et al. Monitoring response to primary

chemotherapy in breast cancer using dynamic contrast‐enhanced magnetic

resonance imaging. Breast Cancer Res Treat 2004; 83:67.

• Pickles MD, Lowry M, Manton DJ, et al. Role of dynamic contrast enhanced MRI in

monitoring early response of locally advanced breast cancer to neoadjuvant

chemotherapy. Breast Cancer Res Treat 2005; 91:1.

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E, Slanetz

P, Kopans

DB, et al. Prospective comparison of mammography,

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chemotherapy for

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chemo‐therapy. Radiol

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P, Heinig

A, Lampe D, et al. Retrospective analysis for evaluation of the

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• Drew PJ, Kerin

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ACKNOWLEDGEMENT

• A special thank you to Dr. Priscilla SlanetzAnd to Dr Gillian Lieberman

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