Download - Sophie Taieb : Breast MRI indication 2014
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Breast MRI Indications 2014 !
Sophie Taïeb, Luc Ceugnart – Centre Oscar Lambret – Lille
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MRI = Poor specificity
Ø 44 studies. 1985 – 2005. 3101 pts,
Ø Se : 90% [0.88-0.92]
Ø Sp : 72% [0.67-0.77]
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Ø 69 studies. 1985 – 2010. 9298 pts, 9884 lesions.
Ø Se : 90% [0.88-0.92]
Ø Sp : 75% [0.70-0.79]
Ø LR+ : 3,64 [3-4,2] Ø LR- : 0,12 [0.09-0.15]
Ø AUC : 0.91 Ø Point Q* : 0.84
MRI = Poor specificity Medeiros LR et al. Breast Cancer Research andTreatment 2011
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False negative lesions Late enhancement
Ø 5 % of cancers ü DCIS. Kuhl et al. Lancet 2007 : 44/89/7139 DCIS high grade
ü Well differentiated carcinomas : Mucinous ü LIC ü Fibrous carcinoma Utility of a late sequence (> 8 mn)
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False positive lesions Benign lesions with early enhancement
Ø Focal enhancement ü Normal breast (1st week or 2nd part of cycle) ü Young fibroadenomas ü Intra breast lymph nodes ü Fat necrosis ü Radial scar ü Proliferative mastopathy with cysts ü Phyllodes tumor(grade 1) ü Post surgery (6 mois) ü Post biopsy
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Ø Diffuse enhancement ü Normal breast (1st week or 2nd part of cycle) ü Hormonal replacement therapy – OC – Mirena IUD ü Proliferative mastopathy with cysts ü Inflammatory breast ü Post radiation therapy
False positive lesions Benign lesions with early enhancement
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Ø Perform in specialist breast units with experience in CI ü At least 150 MRI / year / centre ü MRI biopsy in house or agreement with another institution
Ø Use adequat sequences in adequat period of menstrual cycle (7-12)
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Use adequat sequences
Ø Dedicated breast coil, Bilateral acquisition, 2nd week of cycle Ø At least one unenhanced high-contrast sequence (T2 FSE) Ø 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness < 4mm,
each sequences < 120 sec. At least 8 mn. Ø Gadolinium-chelates 0,1mmol/kg – 2-3ml/s, saline flush
(20-30ml)
Ø Post processing : temporal substraction, dynamic analysis MIP
Ø Not yet assessed in routine practice (2010) : DWI-MRI and H+ Spectroscopy
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Ø Perform in specialist breast units with experience in CI ü At least 150 MRI / year / centre ü MRI biopsy in house or agreement with another institution
Ø Use adequat sequences in adequat period of menstrual cycle (7-12)
Ø Use Birads lexicon to describe lesions
Ø Respect indications
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F A measure of the level of evidence (LoE) from 1a (highest) to 5 (lowest)
F Degree of recommendation (DoR) from A to D, F Clinical recommendations not based on scientific evidence were
explicitly labelled as experts panel opinions (EPO).
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Respect indications
Ø LoE 1,2 ; DoR A,B ü No MRI ü MRI first ü MRI to specify CI
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LoE-1A, DoR-A
1 - No MRI when biopsy can be performed
Ø Birads 3, 4 ou 5 Targets with CI = biopsy ü Calcifications = vacuum assisted breast biopsy ü Nodules = core needle biopsy or VABB
MRI if biopsy not feasable or if discordance between image and VABB (EPO)
2 - No MRI in Young women, with risk < 20-30% for
all life, especially with dense breasts and especially if anxious.
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MRI first in screening of high-risk women Ø Annual MRI : EPO Ø Assessment screening program : recall rate < 10% EPO Ø Begin at 30-year-old : LoE-2b, DoR-B
Dr L.Ollivier
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MRI to specify CI : Ø Evaluation of response to neoajuvant chemotherapy. § If perform : Pretreatment MRI always. LoE-1b; DoR-A § Very low enhancement after ttt is a sign of residual
lesion : LoE1, DoRA § In poor reponders based on clinical examination and CI
no MRI is not useful. EPO
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MRI to specify CI : Ø Evaluation of response to neoajuvant chemotherapy. (LoE-1b;
DoR-A) Ø Breast cancer recurrence (LoE-1b; DoR-A)
ü Difficult Clinical examination, CI and Biopsy ü BUT
* No screening by MRI * MRI after CI + Biopsy (if target)
ü No FP after RT ü FN occur
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1953 2001 : LIC Left breast : BCT 2003 : Mass Biopsy : Normal breast
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1953 2001 : LIC Left breast : BCT 2003 : Mass Biopsy : Normal breast MRI : Fat necrosis : Birads 2 Follow-up : no recurrence
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MRI to specify CI : Ø Evaluation of response to neoajuvant chemotherapy. (LoE-1b; DoR-
A) . Ø Breast cancer recurrence. (LoE-1b; DoR-A) Ø Occult breast cancer (LoE-1b; DoR-A)
ü Not indicated in extensive metastatic disease (EPO) ü If MRI negative avoided surgical treatment of
ipsilateral breast (LoE-2b; DoR-B)
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63-year-old, Left axillary lymph node Ø LIC Ø Negative CI
T2 MIP first Sub
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§ Mass 6mm § Birads 4 : round,
irregular margins, Curve type 3
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§ Left lymph node : CLI
§ R : CCI + CCIS + LN
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MRI to specify CI : Ø Evaluation of response to neoajuvant chemotherapy. (LoE-1b; DoR-
A) . Ø Breast cancer recurrence. (LoE-1b; DoR-A) Ø Occult breast cancer (LoE-1b; DoR-A) Ø Breast implants: augmentation or reconstruction
ü MRI is not a screening tool (LoE-1, DoR-A) ü Implant rupture ? Non contrast MRI (LoE-1a, DoR-
A) ü Recurrence ? Contrast-enhancement MRI (LoE-2,
Dor-B)
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Breast implant rupture
Breast implant capsule
Breast implant wall
Intracapsular Rupture
Extracapsular rupture
Courtesy Dr C.Balleyguier - IGR
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Intra capsular rupture
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Extra capsular rupture
Courtesy Dr C.Balleyguier - IGR
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§ 56 year-old § Breast reconstruction 3 years ago § Direct trauma (Fall off a bike) § US : Intracapsular rupture ?
MRI
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Silicone breast implant MRI = Intracapsulare rupture
T1
T2
STIR
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Silicone breast implant MRI = Intracapsulare rupture
T1
T2
STIR
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T2
Water & Fat sat
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Respect indications
Ø LoE 1,2 ; DoR A,B ü No MRI when biopsy can be performed. Young women ü MRI first : Screening of high-risk women ü MRI to specify CI : Evaluation of response to neoajuvant
chemotherapy, Breast cancer recurrence, Breast implants, Occult primary breast cancer.
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Respect indications
Ø LoE 1,2 ; DoR A,B ü No MRI when biopsy can be performed. Young women ü MRI first : Screening of high-risk women ü MRI to specify CI : Evaluation of response to neoajuvant
chemotherapy, Breast cancer recurrence, Breast implants, Occult primary breast cancer
Ø LoE = 3 – EPO : All MRI as « problèmes solving » : Nipple discharge, Paget disease, AD seen on one incidence…
MRI allows to highlight carcinoma not seen on CI J
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§ 46 year-old § Paget disease § CI : negative
MRI
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§ 46 year-old § Paget disease § CI : negative
§ MRI : 2 biopsies IDC, DCIS
§ P : DCI + comedo carcinoma, 1N+ (GS), GSBR 7, Ki67 35%, RE+, RP-, Her2+
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41 y-o - Nurse Normal physical examination Mother with breast carcinoma under 50 years-old 1st mammography
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US : no lesions seen
BiRads 3 or MRI ?
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BiRads 2
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MRI = PROBLEM SOLVING J
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CONTRALATERAL BREAST
3rd sequence postC T2FS
Ø BiRads 3 Ø US : not seen
Washin card
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Follow up 4 months : Persistence of lesion Biopsy
Failure
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2 Months later : SURGERY MRI wire localization
ü HYPERPLASIA without atypical cells
MRI = Problem creating L
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Respect indications
Ø LoE 1,2 ; DoR A,B ü No MRI when biopsy can be performed. Young women ü MRI first : Screening of high-risk women ü MRI to specify CI : Evaluation of response to neoajuvant
chemotherapy, Breast cancer recurrence, Breast implants, Occult primary breast cancer
Ø LoE 2–DoR=B : Staging before treatment planning Ø LoE = 3 – EPO : All MRI as « problèmes solving » : Nipple discharge, Paget disease, AD on one incidence…
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Staging before treatment planning
Change of treatment planning due to MRI : à Biopsy of additional lesions +++ to avoided
mastectomy due to FP - LoE-1a, DoR-A
(5) – Breast cancer in women < 40 ans
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Ø If MRI = more TM & thus increase overall survival : this is good news
Ø M.Morrow ( Editorial JAMA 2004)
Technological breakthrough = Go back to 70’ for
treatment.
Staging before treatment planning
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Patientes randomisées entre 1975 et 1985
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Ø 50 / 237 – 1996-2011 Ø 10811 pts Ø MRI :
ü 20% ipsilat. lesions more: PPV 59 à 74% à biopsies § Wider excision in 12,8% but 6,3% useless § Local recurrences rate after BCT : 0.5-1% per year
ü 5,5% contralat : PPV 27 à 47% à biopsies
Ø Patients outcome ??
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à 01/2013 Ø 4 studies – 3169 pts, 3180 lesions Ø 1833 no MRI, 1347 MRI. 1 randomized (COMICE), 3 no Ø Median follow-up 2.9 years [1.6-4.5]
ü 64/3169 local recurrences (2%) MRI : 1.8%; No MRI : 2.2% NS
ü 93/2708 distant recurrences (3.4%)
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8-year probability : § LR-free survival for MRI : 97% [95-98] vs no MRI = 95% [93-97] P=.87 § DR-free survival for MRI : 89% [83-93] vs no MRI = 93% [90-95] P =.37
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Ø Preoperative MRI in routine staging does not reduce the risk of LR or DR
Ø Study limitations : ü Only 4 studies ü Only 1 randomized ü Only 8 years probability follow-up ü Contralateral breast : no information
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Staging before treatment planning
Change of treatment planning due to MRI : à Biopsy of additional lesions +++ to avoided
mastectomy due to FP - LoE-1a, DoR-A
(5) – Breast cancer in women < 40 ans
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Ø LoE 1,2 ; DoR A,B ü No MRI when biopsy can be performed. Young women ü MRI first : Screening of high-risk women ü MRI to precise CI : Breast cancer recurrence, breast
implants, Occult primary breast cancer, Evaluation of response to neoajuvant chemotherapy .
Ø LoE = 2 – DoR=B : Staging before treatment
planning Invasive LC, High-risk patients, discrepancy in size between
mammo and US with expected impact on treatment decision
Ø LoE = 3 – EPO : All MRI as « problemes solving » : Nipple discharge, Paget disease, AD on one incidence… MRI as problemes creating…
In summary
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Key points
1. Respect indications – Poor specificity !! 2. Respect technical conditions 3. Use BiRads lexicon (allowed Birads 0) No more problems after MRI than before
ü Explain it to patients ü Explain it to referent colleagues And do it BEFORE to perform Breast MRI