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Recent advances in MRI Breast and Future

Recent advances in MRI Breast and Future

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Recent advances in MRI Breast and Future

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  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 1 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

  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 & SpecificityMammogram Vs Ultrasound Vs MRI Reference: HaithamElsamaloty et al . AJR 2009; 192:1142-1148, 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 50-69 yrs 60-80%

  17. Sensitivity and Specificity of Annual MRI, Mammography, Ultrasound and 6 Monthly CBE in High Risk Women 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 Examples • UK 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

  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

  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

  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

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

  35. Normal side

  36. US Extra capsular silicon

  37. Extra capsular silicon

  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 30-39 yrs: • To women at a 10 year risk >8% • From 40-49 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