1. New Breast MR Imaging
Sophie Taïeb, Luc Ceugnart
Anticancer center Oscar Lambret
- Lille -

2. 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 Respect indications
Ø Use Birads lexicon to describe lesions

3. 35 y-o. BRCa2. Yearly MRI
Right Breast : Mass BiRads 5
• US: mass 25 mm
• IDC grade 3
• RE+, RP-, Her2 -, Ki67 25-30%

4. Right breast 6h : DCIS
• Pas de traduction echo- mammographique

5. Right mastectomy
Ø IDC 16 mm
Ø DCIS 11 mm
Ø 1N+ / 13 N
MRI allows to highlight carcinoma not
seen on mammo or US
J

6. 41 y-o - Nurse
Normal physical examination
Mother with breast carcinoma under 50 years-old
1st mammography

7. US : no lesions seen
BiRads 3 or MRI ?

8. BiRads 2

9. MRI = PROBLEM SOLVING
J

10. CONTRALATERAL BREAST
3rd sequence postC
T2FS
Washin card
Ø BiRads 3
Ø US : not seen

11. Follow up 4 months : Persistence of lesion
Biopsy
Failure

12. 2 Months later : SURGERY
MRI wire localization
Ø HYPERPLASIA without atypical cells
MRI = Problem creating
L

13. The breast MRI we need
Ø Safe : No toxicity (gadolinium-chelates)
Ø High Sensitivity, Specificity, PPV, PNV : Even with low
prevalence of disease
Ø Good reproducibility : Inter et Intra observers
Ø Low coast : Money, Medical’s and Patient’s time
Ø Easy comparison with gold standards
ü Mammo – US
ü Biopsy - Surgery
ü Histopathology

14. The breast MRI we need
Ø Safe : No toxicity (gadolinium-chelates)
Ø High Sensitivity, Specificity, PPV, PNV : Even with low
prevalence of disease
Ø Good reproducibility : Inter et Intra observers
Ø Low coast : Money, Medical’s and Patient’s time
Ø Easy comparison with gold standards
ü Mammo – US
ü Biopsy - Surgery
ü Histopathology

15. MRI = Poor specificity
Ø 44 studies / 251 : 1985 - 2005
Ø Se : 90% [0.88-0.92]
Ø Sp : 72% [0.67-0.77]

16. Ø 11 studies (1994-2007) – No randomised studies
Ø 2 mutations (727), 9 mutations + risk > 15% for all life (4939)
Ø 218 cancers : 3.5% (45) - 2% (171) - 20% DCIS - 60%N+ (126)
Ø Se : Mammo 14-59% ; MRI 51-100%
Ø Sp : Mammo 91-100% ; MRI 79-98%

17. Ø 50 / 237 – 1996-2011
Ø 10811 women
Ø Extension surgery in 12,8% but useless in 6,3% of cases
Ø Miss information about overall survival
Ø MRI :
ü 20% homolat lesions. PPV of cancer : 59-74% à need biopsy
PPV : 75% if > 1,5T ; 59% if < 1,5T
ü 5,5% controlat. PPV of cancer : 27-47% à need biopsy
PPV : 40% if > 1,5T ; 19% if < 1,5T

18. Improve specificity : 3T MRI ?
Ø Adequat sequences : 2nd Week of menstrual cycle
ü At least one unenhanced high-contrast sequence (T2 FSE)
ü 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness
< 4mm, < 120 sec.
ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)

19. Improve specificity : 3T MRI ?
Ø Adequat sequences : 2nd Week of menstrual cycle
ü At least one unenhanced high-contrast sequence (T2 FSE)
ü 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness
< 4mm, < 120 sec.
ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)
Ø Centre Oscar Lambret - 3T : 3D Vibrant (GE)
ü 5 x 80 secondes
ü Pixel 0,66 mm2, Thickness 2,2mm, No Gap.
ü S1 – begining injection 20sec. before the end, 4 post injection

20. Improve specificity : 3T MRI ?
Ø Adequat sequences : 2nd Week of menstrual cycle
ü At least one unenhanced high-contrast sequence (T2 FSE)
ü 2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness
< 4mm, < 120 sec.
ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)
Ø Centre Oscar Lambret - 3T : 3D Vibrant (GE)
ü 5 x 80 secondes
ü Pixel 0,66 mm2, Thickness 2,2mm, No Gap.
ü S1 – begining injection 20sec. before the end, 4 post injection
Ø No studies demonstrate 3T > 1,5T
ü Best spatiale resolution
ü Best temporal resolution : 15 - 20 mn
T1 + T2 + DWI-w + 3D dynamic + Late Sequence (DCIS)

21. Improve specificity : DWI-MRI ?
Ø à 2009 : 13 / 65 études
Ø 615 Cancers, 349 LB
Ø b 1000 -Se : 0.84 [0.8-0.87]; Sp 0.84 [0.79-0.88]

22. ü 93 women, 101 lesions. 3T, b0, b600.
ü 33 BL : 9 FA, 3 intraductal Papillomas, 4 Fibrocystic L, 4 sclerosing aden.
2 ADHL, 11 areas of benign breast tissue
ü 68 K : 23 IDC, 26 IDC+DCIS, 9 DCIS, 6 ILC, 4 others

23. • 27
y-­‐o.
Pregnant
:
8
Weeks
• Le6
B
:
IDC
Grade
3
RE-­‐,
RP-­‐,
Her2
-­‐.

24. • 27
y-­‐o.
Pregnant
:
8
Weeks
• Le6
B
:
IDC
Grade
3
RE-­‐,
RP-­‐,
Her2
–
• Right
B
:
?
S3
Diffusion
b 1000
Native 3
ADC

25. • 27
y-­‐o.
Pregnant
:
8
Weeks
• LB
:
IDC
Grade
3
RE-­‐,
RP-­‐,
Her2
–
• RB
:
?
ADC: 2,
ADC: 0,86.10-3
ADC: 1,26.10- 3

26. • 27
y-­‐o.
Pregnant
:
8
Weeks
• LB
:
IDC
Grade
3
RE-­‐,
RP-­‐,
Her2
–
• RB
:
?
ADENOSIS
ADC: 2,
ADC: 0,86.10-3
ADC: 1,26.10- 3

27. 54
y-­‐o.
MulKfocalité
on
mammography
?
RB
:
2nd
lesion
:
Birads
5

28. 54
y-­‐o.
MulKfocalité
on
mammography
?
RB
:
2nd
lesion
:
Birads
5

29. 54
y-­‐o.
MulKfocalité
on
mammography
?
RB
:
2nd
lesion
:
Birads
5

30. 54
y-­‐o.
MulKfocalité
on
mammography
?
LB
:

31. 54
y-­‐o.
MulKfocalité
on
mammography
?
LB
:
Lymph
node

32. Artefacts
fréquents….
Courtesy Dr C.Balleyguier

33. Improve specificity : Contrast
media ?
Support: Bracco
Ø Centers 17 : 07/2007 – 05/2009
Ø 162 Mammo ou US : Birads 3, 4, 5 (biopsy needed)
Ø 82 Gadobenate Dimeglumine / 80 Gadopentate Dimeglumine
Ø 2nd MRI > 2 days; < 7 days
Ø 136 patients with both. GB : 7 atopic reactions, GP : 6
Ø Independant 2nd reading : 3 readers + 4th review reader

34. Ø 136 double examinations : 216 lesions
Ø 144 cancers :
ü 87 IDC, 30 ILC, 5 both, 5 others
ü 13 DCIS, 3 LN, 1 mixte
Ø 52 Benign lesions
Ø 20 Birads3 : follow-up
Results : 3 readers
Ø Cancer detection rate : GB 91.7, 93, 94.4% > GP 79.9, 80.6, 83.3%
Ø Se : GB 91.1, 94.5, 95.2% > GP 81.2, 82.6, 84.6%
Ø Sp : GB 99, 98.2, 96.9% > GP 97.8, 96.9, 93.8%

35. 50 y-o, DCIS

36. Use Birads to describe lesions
Objective : BiRads : 0? 1? 2? 3? 4? or 5?
1. Density : 1 to 4 ≈ Mammography
2. Background Parenchymal enhancement

37. Use Birads to describe lesions
Objective : BiRads : 0, 1, 2, 3, 4 ou 5 ?
1. Density : 1 to 4 ≈ Mammography
2. Background Parenchymal enhancement
3. Lesion analysis – morphology
ü Detection : 1st post contrast sequence (soust – MIP)
ü Analysis : 2nd post contrast sequence (native – MIP)

38. 3 lesion types :
Ø Foci
Ø Masses
Ø Non-Mass Enhancement
Conclusion:BiRads
0? 2? 3? 4? 5 ?

39. 3 lesion types :
Ø Foci
Ø Masses
Ø Non-Mass Enhancement
Conclusion:BiRads
0? 2? 3? 4? 5 ?

40. Focus

41. 3T, GB
BiRads :
0, 2, 3, 4, 5 ?

42. 45 y-o,
29 y-o,
3T, GB
BiRads :
0, 2, 3, 4, 5 ?
54 y-o.

43. 3 lesion types :
Ø Foci
Ø Masses
Ø Non-Mass Enhancement
Conclusion:BiRads
0? 2? 3? 4? 5 ?
BiRads Mammo & US : According to images alone
BiRads MRI : According to MR images and CI
and 2nd look US and context (and intuition?)

44. 45 y-o, BRCA2
2-2011
29 y-o, BRCA2 –
1st IRM – 1/2010
BiRads :
0, 2, 3, 4, 5 ?
54 y-o.
IDC bi-focal

45. 45 y-o, BRCA2, CI normal
2009
2-2011 BiRads 3

46. 45 y-o, BRCA2 CI normal
2009
2-2011 BiRads 3
6-2011
1-2013
Birads 2

47. 29 y-o, BRCA2 – 1st IRM – 1/2010
2nd look Mammo & US normal
Birads3 D
Birads3 G

48. 29 y-o, BRCA2 – 1st IRM – 1/2010
4/2010

49. 29 y-o, BRCA2 – 1st IRM – 1/2010
4/2010 : IDC, G3, ER+, PR-, Her2-, N-

50. § 54 y-o, Left breast : IDC
8 mm – BiRads6- IDC
BiRads 6 - IDC

51. 54 y-o Left breast : IDC
4,1mm

52. § 54 y-o, Left breast : IDC
Retraction + lesions Birads 6
4,1mm
FOCUS Birads 4 : IDC

53. Kinetic curves
Ø After morphological analysis (Kuhl, AJR 2005)

54. Kinetic curves
Ø After morphological analysis (Kuhl, 2005)
Type 3
Ø (Kuhl, 1999)
57% in carcinoma
5% in benign Lesion

55. Kinetic curves
Ø After morphological analysis (Kuhl, 2005)
Type 1
Type 2
34 % : K
12% : BL
9% : K
83% : BL

56. Foci or UBO (unidentify bright object)
Ø Birads2 if :
ü
ü
ü
ü
< 5 mm,
No associated findings
Not menopausal women, not after radiation therapy
Easier if multiple and bilateral : Background enhancement

57. Foci or UBO (unidentify bright object)
Ø Birads2 if :
ü
ü
ü
ü
< 5 mm,
No associated findings
Not menopausal women, not after radiation therapy
Easier if multiple and bilateral : Background enhancement
Ø Birads3 if
ü 1st MRI in BRACx women
ü Post menopausal or post radiation therapy
ü Unique or few or in not glandular zone of breast.
ü Breast cancer or Birads 5 Lesion in contralateral breast
Follow up : 3/4 months, 6/8 months, 12 months

58. Foci or UBO (unidentify bright object)
Ø Birads2 if :
ü < 5 mm,
ü No associated findings
ü Not menopausal women, not after radiation therapy
ü Easier if multiple and bilateral : Background enhancement
Ø Birads3 if
ü 1st MRI in BRACx women
ü Post menopausal or post radiation therapy
ü Unique or few or in not glandular zone of breast.
ü Breast cancer or Birads 5 Lesion in contralateral breast
Follow up : 3/4 months, 6/8 months, 12 months
Ø Birads 4 Lesion Birads 5 or 6 in same breast = biopsy
PPV of cancer : 3 à 95%
If < 4mm : PPV of biopsy : 0 ; If > 4 mm : PPV of biopsy 20-30%

59. 3 lesion types :
Ø Foci
Ø Masses : MARGIN
Ø Non-Mass Enhancement
Conclusion:BiRads
0? 2? 3? 4? 5 ?

60. RNM

61. NME
Ø 2003-2005 : 1523 MRI / 1128 p
Ø 258 L BiRads 4,5 – 196 p : 186 LB, 72 Cancers (21 DCIS, 34 DIC
11 LIC, 6 others)
Ø 95 NME
ü 27 M
ü 68 B

62. NME
Ø 2008-2009 : 131 NME / 115 p – Breast cancer 46, HR 29, PS 40
Ø 63 BL, 12 FL, 56 Cancers

63. NME symmetric, focal, bilateral :
BiRads 2

64. NME, asymmetric : not so easy

65. NME, asymmetric : not so easy
Radiation therapy of the Left B 5 years ago …
BiRads2

66. 49 y-o, BRCA2, first MRI
ACR4 : DCIS

67. NME

68. 2mn
T2
6mn
T1

69. 4/5

70. 4/5
4/5

71. 4/5
4/5
3

72. 4/5
131 L
31 Birads 3 : 1 C
100 BiRads 4/5 : 56 C ou FL
4/5
FP : 74/131 (55%)
4/5
4/5

73. 2nd look US - Biopsies
Ø Visibility : Masses 57- 62%, NME 12-31 %

74. 2nd look US - Biopsies
Ø Visibility : Masses 57- 62%, NME 12-31 %
Ø PPV of K if lesions seen on 2nd look US or not
ü Demartini, 2009 : (167) 36%
- 22%
ü Abe, 2010 :
(202) 29%
- 13%
If MRI + and US - : 13 à 35% K à Biopsy always ++

75. 2nd look US - Biopsies
Ø Visibility : Masses 57- 62%, NME 12-31 %
Ø PPV of K if lesions seen on 2nd look US or not
ü Demartini, 2009 : (167) 36%
- 22%
ü Abe, 2010 :
(202) 29%
- 13%
If MRI + and US - : 13 à 35% K à Biopsy always ++
Ø Meissniger, 2009 : Corrélation MRI / US : 519
ü 56% ok : 62% if masses – 31% if NME
ü 80 US Biopsy for BL
10 lesions not same on MRI and US : 9 cancers
Thomassin et al. Breast Cancer Res Treat. 2012 A plea for the biopsy
marker: how, why and why not clipping after breast biopsy?

76. The breast MRI we need
Ø Safe : No toxicity (gadolinium-chelates)
Ø High Sensitivity, Specificity, PPV, PNV : Even with low
prevalence of disease
Ø Good reproducibility : Inter et Intra observers
Ø Low coast : Money, Medical’s and Patient’s time
Ø Easy comparison with gold standards
ü Biopsy
ü Surgery
ü Histopathology

77. The breast MRI we dream
Ø No contra indications
Ø Suppine position likes US, Surgery and radiotherapy
Ø No contrast need
Ø Few sequences to characterize (without doubts)
ü Lesions
ü Treatment response
Ø Uncertainties of radiological analysis easy to explain
to referent collegues and patients …
(with color and arrows to help them to find target –
may be a need for radiologist also)

78. SUPPINE POSITION
ü ECR 2013 : B- 0325 = Meilleure délimitation pour le boost de
radiothérapie

79. SUPPINE POSITION
Nakano et al. Breast Cancer Research and Treatment 2012
ü 196 patients MRI in suppine position. 67 lesions in 55p.
ü 24M, 43B
ü 2nd look sonogrphy : real-time virtual sonography
Real-time US
Pre-contrast T1WI
Early phase T1WI Late phase T1WI

80. ECR 2013 : No contrast
ü B- 0453 = FSET2 ideal + Diff (3T, 31 cas)
No contrast needed for response assessment after
neoadjuvant Chemotherapy
ü B- 0954 = Multi spectral sequences with T1 and T2
cartography
§ 46 lesions (18 B, 28 M)
§ Ratio T1/T2 élevé dans K

81. Key points
1.
2.
3.
4.
Respect indications
Respect technical conditions
Use BiRads lexicon (allowed Birads 0)
3T, Contrast-media, DWI-MRI helpfull
No more problems after MRI than before
ü Explain it to referent collegues
ü Explain it to patients
Before to perform Breast MRI

82. Thank you