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BREAST MRI
Equipment
Technique
Breast MRI BI-RADS
Richard Tuft Indications
FRCS, FRCR, FFRad(D)(SA) Biopsy
ISRRT Durban 2008

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Equipment Sequences and Technique

„ 1.5T Minimum „ Fat saturation

„ 3.0T Ideal „ Pre contrast STIR (T2 Fat Sat)
„ Detachable tables „ Pre and post contrast FLASH3D (T1 Fat Sat)
„ Temporal and spatial sequences
„ Subtraction
„ Morphology and Kinetics
„ Scoring (BI-RADS)
„ Chest and upper abdomen staging studies
„ Prosthesis analysis

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When to scan Sequences

„ Pre-menopausal day 10-15 „ Chest and Liver STIR

„ 6 Months after surgery „ Breast STIR
„ 12 months after radiotherapy „ Precontrast 3DFLASH
„ Consider discontinuing HRT for 4-6 weeks „ Postcontrast 3D FLASH with timed measurement of
Contrast uptake
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FAT SATURATION Pre-Contrast STIR with Fat Sat

„ The key „ Axillae

„ Fat sat failure „ Chest wall
„ Patient weight „ Cysts
„ T2 Without Fat Sat

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FLASH 3D High-spatial Resolution: delayed "VIEWS"

„ After dynamic exam.

„Pre and Post
„ Increased Resolution
Contrast „ Thin planes
„Morphology
„Kinetics
„Subtraction

Courtesy of FHDI

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Multi-modality Approach: The Key MR / Mammo Correlation: Oblique MIP / MLO

High-resolution Compound US

Mammography Courtesy: Dr. Bruce Porter

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Sagittal display: Sagittal display:

„ Multiplanar reconstruction from

„ Dynamic VIEWS
„ Delayed VIEWS
„ Sagittal bilateral acquisition

SAG delayed VIEWS

Sagittal
reconstruction of
90 second
Dynamic VIEWS
acquisition

Courtesy of FHDI

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Kinetics 3D fat-saturation dynamic VIEWS

Angiogenesis
„ Tumour angiogenesis
promotes a rich high density
network of tumor vessels. 1 min
„ > 3mm, malignant infiltration,
and metastatic disease.
Pre-contrast
„ Enhancement quantification
(dynamic MR) allows detection 2 min
Inline dynamic MIP
of tumors to ~ 3 mm.,
regardless of their
morphology… 3 min
1 minute subtraction

Courtesy of CSMC

4 min

5 min

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Subtraction Kinetics

„ Find enhancing area

„ Apply ROI
„ Assess Kinetics

I---------- 3-D Dynamic --------II--------------- VIBE ---------------I

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Enhancing Breast Cancer Features of Breast Malignancy:

Morphology

Kinetics
Courtesy: Dr. Bruce Porter

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BI-RADS Grading BI-RADS®

„Published by ACR „0 - Incomplete exam „ 1 Normal Benign

„Mammography „ 2 Benign
„1 - Normal
„ 3 Probably Benign Imaging follow up or tissue
„Ultrasound „2 - Benign „ 4 Probably Malignant TISSUE
„MRI „3 - Probably Benign „ 5 Malignant TISSUE
„4 – Probably Malignant
„5 – Malignant
„6 – Biopsy Proven
Cancer

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BI-RADS MRI Scoring MRI Scoring System (Gottingen score)

„MRI Artefact Category „1-4

Points 0 1 2
Shape -
„Density Type „1-4 Margins Well -defined Poorly defined
Contrast Homogenous Inhomogeneous Ring
Initial Inc <50% 50-100% >100%
Post Initial Increase Plateau Washout
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MRI BI-RADS Enhancing Breast Cancer

„0 Points „MRI BI-RADS 1

„1-2 Points „MRI BI-RADS 2
„3 Points „MRI BI-RADS 3
„4-5 Points „MRI BI-RADS 4
„6-8 Points „MRI BI-RADS 5

7 Points = BI-RADS 5

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Breast Cancer Breast MRI

Indications
„ Screening
„ Assessment and staging of breast cancer
„ Prostheses

1 in 8 women will be diagnosed with breast cancer

Assuming a woman lives to the age of 85

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MRI Breast Screening MRI Breast Screening

„ NEJM July 2004 „ 52 Tumours

„ 1909 high risk women „ 44 Invasive carcinomas
„ Risk > 15%, genetic or familial „ 6 DCIS
„ 358 BRCA1 or BRCA2 positive „ 1 Lymphoma
„ 1 LCIS
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MRI Breast Screening MRI Breast Screening

„ Sensitivity „ Specificity
„ Clinical 17.9 „ Clinical 98.1
„ Mammography 33.3 „ Mammography 95.0
„ MRI 79.5 „ MRI 79.5

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American Cancer Society Guidelines for
Breast Screening with MRI as an Adjunct
to Mammography
„ March 2007
„ Screening MRI is recommended:
„ for women with an approximately 20–25% or greater lifetime
risk of breast cancer,
„ including women with a strong family history of breast or
ovarian cancer and
„ women who were treated for Hodgkin disease.
Non-Screening Clinical Indications for Contrast
Breast MR
„ Lobular Cancer
„ Occult Breast Cancer
„ Close or positive surgical margins
„ Post-operative scar vs. tumor recurrence
„ Neo-adjuvant chemotherapy or brachytherapy
„ Suspected multiple or bilateral cancers
„ Implants and known or suspected cancer
„ Problematic Mammogram
„ Assessment of all diagnosed breast cancers.

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MRI in unilateral breast cancer MRI in diagnosed breast cancer

„ NEMJ March 2007 „ April 2008

„ 969 with diagnosis of unilateral breast cancer
„ Other breast normal clinically and mammo
„ Occult cancer in second breast 3.1%
„ European Breast Cancer Conference in Germany
„ 249 patients who had malignancy on biopsy had MRI
„ Altered management in 13%
„ 20 additional cancers – 8%
„ Better than mammo or US in assessing tumour size
„ “We would like to see MRI become a standard preoperative
treatment for breast cancer, along with biopsy,
mammography, and ultrasound”
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Analysis

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Unilateral vs. Bilateral Multiple lesions

Fibroadenoma
Infiltrating ductal Ca

„ Cancers are
bilateral in up to
10%

„ Exclusion of
contra-lateral tumor
is of great clinical
and personal value

Courtesy: Dr. Bruce Porter

Courtesy of FHDI

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DCIS
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Pathology with prostheses Prostheses with pathology

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Extent of Tumour Lobular carcinoma larger than Mammo or

US

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Incomplete Excision Neo-adjuvant Chemotherapy: Monitoring

Post-chemo
Courtesy of FHDI
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Contrast-enhanced Breast MR: Accuracy Staging

„ Varies significantly with technique and experience.

„ Sensitivity: > 94 – 98 %
„ Negative Predictive Value: > 95 %
„ Specificity: 37 – 97 %
„ Positive Predictive Value: ~ 65- 75 %
„ For DCIS sensitivity is lower, especially for low or
intermediate grades; also for some lobular, low grade, or
less angiogenic invasive carcinomas.

Courtesy: Dr. Bruce Porter

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Chest STIR: Aids in cancer staging MR - guided breast biopsies

„ Look for highest positive lymph node

„ Some lesions are not visible with mammography or
„ Use body coil, supine placement ultrasound (US)
„ After identified with MR (diagnosis)
„ Many lesions can be found using US
„ US is interactive, cheaper, faster
„ MR-guided BB needed for those lesions which cannot be seen
in retrospect on US or mammaography

Courtesy of FHDI

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MRI Breast Biopsy Device Breast Biopsy

„ Lateral and medial access

„ Needle or wire placement
(core, fna)
„ Vacuum assisted biopsy
extraction
„ Software controlled
guidance
„ Comfortable patient
support
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Spectroscopy - MRS MRS monitoring of Chemotherapy

„ Early results show specificity

„ > 95% Before
„ Choline peak at 3.6 ppm Chemo- 1st
therapy
„ Single voxel studies cycle

2nd 3rd
cycle cycle

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MRS monitoring of Chemotherapy Silicone Implant Rupture MRI

„ MR is the definitive exam for implant

assessment.
„ Non-contrast unless a question of
cancer.

4th cycle 5th cycle 6th cycle Silicone

Courtesy of FHDI and USCD

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Implant rupture Conclusion

„ MRI is the ‘gold standard’ if resources are available.

„ Combined approach with Mammogaphy and Ultrasound.
„ Should be used for screening high risk cases.
„ Should be used to assess all diagnosed breast cancer.
„ Use scoring system and BI-RADS
„ You will get false positives
„ No false negatives
„ Don’t screen unless you can biopsy.
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Thank you!
Richard Tuft
FRCS, FRCR, FFRad(D)(SA)
ISRRT Durban 2008