1. Current & Potential Utility of MRI in Diagnosis & Management of Breast Cancer By: Dr. Norran Hussein, MS Cairo University

4. A basic MRM 1) Dynamic 2) Subtraction 3) Curve pre 1 min 2 min 3 min 4 min 5 min

5. A basic MRM 1) Dynamic 2) Subtraction 3) Curve 1 minute subtraction pre 1 min

6. MRI BIRADS Lexicon Is it a : Mass Focus Non mass like Enhancement Other findings? Kinetic Curve analysis Shape Margin Distribution Symmetrical/ Assymetrical BIRADS Category Enhancement Pattern

7. Post operative/ Radiated Breast

8. Post Operative& Radiated 58 year old woman who underwent left lumpectomy for Ca Breast 2 years before, followed by sessions of Radio & chemotherapy which were completed 3 months later. Bilateral MLO Mammography Ultrasonography of the scar L R

9. Case 6 Axial Subtraction Saggital T2 Axial T1 Axial T2 IR MIP

10. Axial Dynamic post contrast Fat suppressed FLASH, with signal-time analysis curve Pathology: Recurrent Invasive Duct Carcinoma

11. Dense Breast

12. Malignant LN searching for a 1ry

14. Pre operative evaluation 47 year old patient presenting with Left breast lump.

15. T2 IR Subtraction T1/ Gd

16. Case 3 Diagnosis: Lt UOQ Invasive Duct Carcinoma

17. Pre operative A 43 year old woman presenting with a left breast lump

18. Pre operative

19. Follow up chemotherapy Pre treat. Post treat.

20. MRI of Implant Failure

21. Fibrous capsule Fibrous capsule Radial folds Radial folds Normal Implants

22. MRI of Implant Failure Suspicious Findings: Loss of Round or Oval form Contour Bulge

23. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Capsular contracture occurs when the AP diameter of the implant is nearly equal to the TS diameter. (normally AP:TS ratio is 1:2)

24. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Axial T2 Fat Sat shows collapsed shell with residual saline The saline is usually absorbed, and linguine sign is not visible in saline implants

25. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Saline outside fibrous capsule

26. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Inverted tear drop C sign

27. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Key hole sign

28. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Linguine Sign

29. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture In double lumen implants, if the inner shell ruptures, a mixture between the saline and silicone occurs: The salad oil phenomenon.

31. MR Diffusion ADC maps in a patient with a malignant breast Tumour. Images are shown in 8 spatial locations with the tumour seen as a hypointense area on the last 2 images.

32. Hyperintense region of in the ADC map representing a cyst. MRI T2WI ADC Map

33. ADC maps in a patient with a malignant breast lesion. Images of 8 spatial locations show the decreased ADC values of the tumour. Other hypointense areas were attributed to fat.

34. Normal MRS of the Breast 7 6 5 4 3 2 1 0 -1 Frequency (ppm) Fat Choline Water Un Sat FA Un Sat FA

39. However….. Lesion size Magnet strength Lactating breast < 2.5 2.5 – 4.9 > 5.0 (cm 3 ) Probability (%) The Probability to Detect Choline in Breast Cancer is Higher in the Larger Lesions

43. 1 H-MRS of Breast Carcinoma H 2 O Fat Cho Cho

45. Mastopathy in a 48-year-old woman

46. Response to chemotherapy A promising application is the use of breast MRS for predicting response to cancer treatment. Current clinically available methods such as palpation and imaging rely on changes in tumor size, which take several weeks before any changes are detectable. Breast MRS, in contrast, reflects changes in intracellular metabolism that would occur before any gross morphological change.

47. Response to chemotherapy In the results of a study presented in RSNA 2003 meeting: 12 women with biopsy proven Ca, were examined with MRS before and within 24hrs of chemotherapy. Patients which showed decreased choline within 24hrs showed a tumour reduction size, after 12 wks of ttt. Patients with cte or elevated choline within 24hrs, failed to have anatomic response to therapy.

48. Axilla

49. Addition of MRS to MRI improved specificity from 62.5% to 87.5% (Huang et al,2004)

52. Conclusion

54. MR guided Stereotactic Biopsy Prone biopsy apparatus Supine biopsy apparatus

55. MR guided Biopsy

59. Thank You

61. Indications Post operative Breast Dense Breast at high Risk Evaluation of axillary nodes MRS

62. Limitations Specificity Calcifications DCIS MRI Inflammation vs Ca

63. Mass Surrounding Non mass like Enhancement Morphology: Shape: round Margin: spiculated Enhancement pattern : rim Other: skin thickening, oedema Kinetic curve: Initial Rise: slow Delayed Phase: persistent Category : BIRADS 4 Pathology: Recurrent Invasive Duct Carcinoma Morphology: Distribution: diffuse Enhancement pattern : heterogenous asymmetrical Kinetic curve: Initial : rapid Delayed : persistent Category: BIRADS 4 Left Breast

64. Case 9: Lexicon Mass Focus Non mass like Enhancement Morphology: Shape: irregular Margin: spiculated Enhancement pattern : thick rim Other: skin thickening Kinetic curve: Initial Rise: rapid Delayed Phase: persistent Category : BIRADS 5

65. Case 8: Lexicon Multiple Masses & Foci Morphology: Shape: irregular Margin: spiculated Enhancement pattern : heterogeneous Other: skin thickening, mammary edema, chest wall edema, Lymph nodes Kinetic curve: Initial Rise: rapid Delayed Phase: plateau & persistent Category : BIRADS 5 Diagnosis: Recurrent Left Multicentric Invasive Ductal Ca

66. Follow up chemotherapy A 55 year old woman who underwent left conservative surgery 1year & 4 months ago followed by radio& chemotherapy. Ultrasonography of the right breast Mammography L R

67. Case 8 Axial T1 Axial T2 IR Saggital T2 Axial Subtraction

68. Case 8 MIP Axial Dynamic post contrast Fat suppressed FLASH, with signal-time analysis curve

69. Pre operative: a 43 year old lady presenting with a right breast lump & axillary swelling. The examination was performed during the 2nd week of the menstrual cycle.

73. MRI Appearance of Various Implants Single lumen Silicone Saline Water suppressed T2 WIs of single lumen silicon implant Axial T2 Fat Sat

74. MRI Appearance of Various Implants Single lumen Double lumen silicone saline

75. MRI Appearance of Various Implants Single lumen Double lumen Fat suppressed T2 W water suppressed T2 W

76. MRI Appearance of Various Implants Single lumen Double lumen Multicompartmental Outer saline & 2 inner silicone comaprtments

77. MRI Appearance of Various Implants Single lumen Double lumen Multicompartmental Single lumen silicone with saline Injection

78. MRI of Implant Failure

79. Fibrous capsule Fibrous capsule Radial folds Radial folds Normal Implants

80. MRI of Implant Failure Suspicious Findings: Loss of Round or Oval form Contour Bulge

81. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Capsular contracture occurs when the AP diameter of the implant is nearly equal to the TS diameter. (normally AP:TS ratio is 1:2)

82. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Axial T2 Fat Sat shows collapsed shell with residual saline The saline is usually absorbed, and linguine sign is not visible in saline implants

83. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Saline outside fibrous capsule

84. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Inverted tear drop C sign

85. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Key hole sign

86. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture Linguine Sign

87. MRI of Implant Failure Diagnostic Findings: Deflation Capsular Contracture Extracapsular Rupture Intracapsular Rupture In double lumen implants, if the inner shell ruptures, a mixture between the saline and silicone occurs: The salad oil phenomenon.