Breast MRI at Lowell General Hospital

1. Breast MRIat Lowell General Hospital Jonas Berman, MD January 21, 2009

2. Lowell General Hospital

3. “In this defining moment,a change has come to Lowell General”

4. Breast Cancer Overview • >250,000 new cases diagnosed each year • 2nd leading cause of cancer deaths in women

5. Of newly diagnosed cases of breast cancer, more than half are candidates for breast conservation

6. Various studies indicate that 15%-50% of patients with known breast cancer will have their management altered by further evaluation with ultrasound or breast MRI

7. Of these patients whose management is altered, 30%-50% will be demonstrated to have other foci of malignancy.

8. When an MRI of the breast identifies a lesion not originally identified on conventional imaging, a second, focused ultrasound will identify 50% of these lesions, which can then be biopsied conventionally. The other 50% need MRI guided biopsy.

9. Background: What is MRI? • 􀂉 Uses magnetic fields to produce detailed cross-sectional images of tissue structures • 􀂉 Uses injected contrast agents to distinguish fat, glandular tissue, lesions, etc. in the breast • 􀂉 Different factors contribute to the measured signal that determines the brightness of the tissues in the image • 􀂉 Contrast agent provides reliable detection of cancers and other lesions. • 􀂉 Screening MRI requires appropriate techniques and equipment (including dedicated breast MRI equipment) and experienced staff

10. Technical Requirements For Good Cancer Detection: • High-field breast MRI (1.5T or >) • Gadolinium-DTPA injection • Dedicated bilateral breast coil • Good fat suppression techniques • High-resolution 3D gradient echo pulse sequence

13. Contraindications Cardiac pacemakers, Ferromagnetic intracranial aneurysm clips Neurostimulators Cochlear implants Ferromagnetic implants, devices, foreign bodies, electronic devices. ACR practice guideline

14. Pregnancy/Lactation No known adverse effects Gadolinium does cross placenta into fetus minimally secreted in breast milk ACR practice guideline

15. Clinical Indications for Contrast enhancedBreast MRI: • Search for primary breast cancer in women with a positive axillary node • Staging of tumor extent in women with a known breast cancer – MRI most accurate • Search for multifocal, multicentric or bilateral breast cancer in women with a known breast cancer

16. Clinical Indications for Contrast enhancedBreast MRI: • Search for residual tumor shortly after surgery in patients with + margins • Evaluation for tumor recurrence after surgery and/or radiation • Monitoring tumor size and extent in neoadjuvant chemotherapy • Screening of high-risk women

17. Why Gadolinium is Essentialfor Cancer Detections T1W-Gradient-echo Pre- Gd T1W-Gradient-echo 2 minute Post Gd

18. Why Gadolinium is Essentialfor Cancer Detection T1W-Gradient-echo 2 minute Post Gd T1W-Gradient-echo Pre-Gd

19. Subtraction Image Sagital Maximum Intensity Projection (MIP)

20. Gadolinium Kinetics Enhancement Kinetics • Rate-how fast • Percent-how much in • Washout- how fast out

23. “Screening” MRI • Who is at High Risk? • 􀂉 Family history suggestive of inherited gene mutation; risk is calculated by assessment models/tools • 􀂉 Genetic testing for mutation in BRCA1/2, TP53, or PTEN • 􀂉 Review of clinical history • 􀂾 Treated for Hodgkin disease • 􀂾 LCIS, ALH • 􀂾 ADH, DCIS • 􀂾 High mammographic density • 􀂾 Personal history of breast cancer

24. Summary of ACS Recommendations (2007) • Recommend Annual MRI Screening (based on evidence) • BRCA mutation • 1st degree relative of BRCA carrier, but untested • Lifetime risk ~20-25% or greater, as defined by BRCAPRO or other models that are largely dependent on family history

25. Summary of ACS Recommendations cont’d • Recommend Annual MRI Screening (based on expert consensus opinion) • Radiation to chest (e.g. Hodgkin disease survivors) between ages 10-30 • Li Fraumeni syndrome,Cowden, Bannayan-Riley-Ruvalcaba syndromes

26. Summary of ACS Recommendations cont’d • Insufficient Evidence to Recommend For or Against MRI Screening • Lifetime risk 15-20%, as defined by BRCAPRO or other models that are largely dependent on family history • LCIS, ALH, ADH • Dense breast tissue • Personal history of breast cancer, including DCIS

27. Summary of ACS Recommendations cont’d • Recommend Against MRI Screening (based on expert consensus opinion) • Women at <15% lifetime risk

28. Breast Cancer Risks for Hypothetical Patients,Based on 3 Risk Models • Family History BRCAPRO Claus Tyrer-Cusick • 35year-old woman Mother BC 33 19% 36% 28% Maternal aunt BC 42 • 35-year-old woman 23% 24% 32% Paternal aunt BC 29, OC 49 Paternal grandmother BC 35 • 35-year-old woman 18% 24% 31% Paternal aunt BC 29 Paternal grandmother BC 35 • 35-year-old woman 13% 18% 23% Mother BC 51 Maternal aunt BC 60

31. Indications for Diagnostic MRI Lesion characterizations Mammographically dense breast Scar vs recurrent cancer Silicone augmented breast Neoadjuvant chemo – extent of disease Infiltrating lobular cancer – extent of disease Infiltrating ductal cancer – extent of disease Axillary adenopathy – primary unknown Post tissue reconstruction – recurrence Implant – integrity/ rupture ACR practice guideline

32. SILICONE IMPLANT EVALUATION • MRI shown to be superior in detecting rupture Goodman C M et al, Ann Plas Surg. 1998:41:577-586 • Mean Sensitivity Mammography 28% Ultrasound 59% MRI 78%

33. Silicone implants

34. Silicone implants

35. Indications for diagnostic MRI Invasion to deep fascia Contra lateral breast cancer Post lumpectomy residual disease – close margin on path Recurrence of cancer when other modalities inconclusive ACR practice guideline

36. Evaluate for recurrent or contralateral tumor

37. Evaluate for recurrent or contralateral tumor

38. cysts

39. cysts

40. 32 yo with bx proven FA with new palpable lesion

41. 32 yo with bx proven FA and new lesion

42. 32 yo with bx proven FA

43. 32 yo with bx proven FA

44. 41 yo with palp nodule RUIQ

45. 41 yo with palp nodule RUIQ

46. 41 yo with palp nodule RUIQ

47. 41 yo with palp nodule RUIQ

48. 41 yo with palp nodule RUIQ

49. MRI-GUIDED BREAST BIOPSY Appropriate for suspicious lesions found on MRI & not seen on mammography or US Equipment Needed: A dedicated breast coil A biopsy guidance system compatible with the breast coil and tissue sampling device A MR-compatible tissue sampling device: - 14 gauge cutting needle - 8-11 gauge vacuum-assisted sampling