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MR an indispensable tool in Saint Barnabas’s breast imaging program

Best Practice
Friedman, Paul, D.O. Livingston, N.J. Saint Barnabas Ambulatory Care Center USA
Wehmann, Claudia Philips Healthcare Philips Global

MR an indispensable tool in Saint Barnabas's breast imaging program

 

As clinicians look for better ways to detect and diagnose breast cancer, MR is emerging as a critical modality - particularly for women at high risk for breast cancer and those who have dense breasts or breast implants. For example, MR is proving extremely beneficial in pre-operative planning for patients undergoing breast-conserving procedures. Radiologist Paul Friedman, D.O. and his colleagues at Saint Barnabas Ambulatory Care Center (Livingston, N.J., USA), began using MR on a limited basis in the early 1990s to aid in lesion detection. Since then,The Breast Center was created, and in 2001, Saint Barnabas began integrating MR into its breast diagnostic services and enlisting radiologists and other breast disease experts to read MRIs.

 Paul Friedman, D.O., and Christine Menendez, M.D. Robert Smith, R.T., performs a breast MRI scan. Saint Barnabas Ambulatory Care Center.
Paul Friedman, D.O., and Christine Menendez, M.D.
Robert Smith, R.T., performs a breast MRI scan.
Saint Barnabas Ambulatory Care Center.

Cancer program dedicates Intera 1.5T for breast imaging

Although Saint Barnabas's breast cancer program employs many diagnostic tools - including mammography, ultrasound, stereotactic biopsy and cyst aspiration - its Intera 1.5T system offers several clinical advantages. Operating since 2001 and dedicated to breast imaging, the Intera is called upon in the 10-15% of cases in which mammography or other modalities have given inconclusive results.

 

"The breast MR exam gives us a true 3D perspective of the breasts, from top to bottom and front to back, as well as the chest wall and axilla," Dr. Friedman says. "Such a comprehensive view and evaluation of the breast is impractical with mammography. MR provides a high degree of sensitivity - so it is especially helpful in evaluating suspicious lesions in women with dense breasts. Moreover, breast MR utilizing contrast agent can reveal lesion angiogenesis and vascularization, as well."

SENSE improves image quality, speeds scans

In November 2002, Saint Barnabas began using SENSE and a prone breast positioning device for all patients. Unlike most centers - which image one breast at a time - this device enables Saint Barnabas clinicians to image both breasts at once. Philips clinical scientist Sri Swaminathan, Ph.D., was involved in on-site optimization of the SENSE protocols. SENSE (factor 3) has increased both temporal and spatial resolution, improving depiction of lesion margins and in turn yielding fewer false positives and false negatives.

 

"Two years ago, before we began using breast MR, some lesions would appear benign when in reality they were malignant," Dr. Friedman says. "Mammography sometimes depicts lesions as more rounded with wellcircumscribed borders, whereas the spatial resolution MR affords - and the ability to use < 1 mm thick slices - shows spiculated and irregular margins much more readily, prompting immediate biopsy rather than a short-term follow-up." SENSE also enables clinicians to create better time intensity curves to assess the lesion's contrast uptake. An evaluation of a lesion's contrast dynamics can assist in diagnosis.

 

 73-year-old female with prominent right axillary lymph nodes. MRI performed to evaluate for a primary carcinoma. 3D T1w FFE, SENSE factor 3, 1.4 x 1.4 mm2 resolution, 80 slices, ProSet fat suppression. MRI revealed an irregular homogeneous enhancing mass. MR-guided excisional biopsy revealed invasive ductal carcinoma. 45-year-old female with palpable right axillary lymph nodes. Negative mammogram and ultrasound. Image from 4th time point of dynamic 3D T1w FFE of both breasts, SENSE factor 3, 1.4 x 1.4 mm2 resolution, 80 slices, ProSet 121 fat suppression. MRI revealed a regional area of heterogeneous enhancement. MR-guided excisional biopsy revealed a large area of invasive ductal carcinoma. 33-year-old female with asymmetric breast tissue in the left breast on recent mammogram and family history of breast cancer. Dynamic 3D T1w FFE of both breasts, SENSE factor 3, 1.4 x 1.4 mm2 resolution, 80 slices, ProSet 121 fat suppression. MRI revealed a focal area of  eterogeneous enhancement in the upper outer quadrant of the left breast. MR-guided excisional biopsy revealed a focal area of dense stromal fibrosis.
73-year-old female with prominent right axillary lymph nodes. MRI performed to evaluate for a primary carcinoma. 3D T1w FFE, SENSE factor 3, 1.4 x 1.4 mm2 resolution, 80 slices, ProSet fat suppression. MRI revealed an irregular homogeneous enhancing mass. MR-guided excisional biopsy revealed invasive ductal carcinoma.
45-year-old female with palpable right axillary lymph nodes. Negative mammogram and ultrasound. Image from 4th time point of dynamic 3D T1w FFE of both breasts, SENSE factor 3, 1.4 x 1.4 mm2 resolution, 80 slices, ProSet 121 fat suppression. MRI revealed a regional area of heterogeneous enhancement. MR-guided excisional biopsy revealed a large area of invasive ductal carcinoma.
33-year-old female with asymmetric breast tissue in the left breast on recent mammogram and family history of breast cancer. Dynamic 3D T1w FFE of both breasts, SENSE factor 3, 1.4 x 1.4 mm2 resolution, 80 slices, ProSet 121 fat suppression. MRI revealed a focal area of eterogeneous enhancement in the upper outer quadrant of the left breast. MR-guided excisional biopsy revealed a focal area of dense stromal fibrosis.

Breast MR exam is straightforward, fast

Saint Barnabas's breast MR procedure is relatively easy for the medical staff and patients. An IV is placed in the patient's forearm and she is positioned prone on the MR table with her breasts in the breastspecific imaging coil to achieve optimal SNR.

 

"It's important that the patient is positioned comfortably and remains still to avoid motion artifacts," Dr. Friedman explains. "She is advanced into the MR scanner, and at least one sequence is obtained using contrast agent administered intravenously. Premenopausal women should have the study during days 6-17 of the menstrual cycle to cut down on false positives, as it is believed there are fewer potential changes in the breast during this time."

 

From a technical standpoint, the process is similar to other contrast studies and the technologist performs some post-processing techniques including subtraction, he says.

 

Fat suppression is accomplished using ProSet, which Dr. Friedman says works very well for the breast.

 

Saint Barnabas's four-sequence breast MR protocol includes T1- and T2-weighted axial and sagittal acquisitions, followed by the T1-weighted dynamic contrast-enhanced acquisition covering seven time points and with ProSet fat suppression.

 

The final sequence is a 3D high-resolution (512 x 512 with 1 x 1 x 1 cm3 voxels) scan. The total scan time is approximately 20 minutes.


Advanced methods

Pre-surgical MR needle localizations are more complex and require additional training. Saint Barnabas performs approximately three of these 45-minute procedures per week. "This method is used when we find a lesion on MRI that isn't visualized on a second look mammogram or ultrasound," he says. "A grid with compression - similar to that used in mammography needle localization - is placed on the patient's breast and she is then scanned using axial, sagittal and dynamic sequences. We obtain coordinates by counting grid boxes, then guide the needle - with its internal hook and wire - into the appropriate area. The needle then comes out, leaving the wire and hook in the breast. The surgeon then removes the region in which these localization devices are positioned."

 

Recently, Saint Barnabas has begun assessing the value of a DWI sequence for lesion characterization. "We just add a quick DWI acquisition at the beginning of the protocol," Dr. Friedman says. "We retrospectively compare our T1- and T2-weighted scans and the dynamic series to try to determine relationships between the lesion's status and its diffusion characteristics. It's still early, but the literature suggests that hypercellular tumors have lower ADC values, indicating more restricted diffusion."

MR useful for pre-surgical survey

Dr. Friedman's colleague, Elissa J. Santoro, M.D., breast surgical oncologist at Saint Barnabas and a breast surgery pioneer in New Jersey, sees breast MR as a valuable tool for pre-operative planning and early detection.

 

"I order pre-operative MR studies for all of my breast cancer patients," she says. "It not only helps measure the size and location of lesions to determine the best surgical approach, but it also helps identify additional atypical lesions that weren't detected with other diagnostic tests. MR is also useful for evaluation of tissue with scarring from radiation or surgical biopsy. Breast MR may eventually become standard practice for pre-operative evaluation in breast cancer surgeries."

When is breast MR appropriate?


Women are usually referred to Saint Barnabas for an MR evaluation by their OB/GYN doctor or breast specialist.While mammography is still the primary screening method, there are a number of indications employing MR as a supplemental tool:

 

 To look for occult lesions in patients with dense breast tissue.

 

 To better characterize atypical lesions.

 

 Evaluation of high-risk patients including women with hereditary predisposition to cancer.

 

 To evaluate patients with a recognized genetic mutation (BRCA1 or BRCA2 genes).

 

 To further assess patients with indeterminate mammograms.

 

 To evaluate the extent and exact location of lesions before surgery.

 

 To monitor a patient's response to therapy.

 

 An evaluation method for women with breast implants.


MR wins in patient comfort category

From a patient's viewpoint, MR offers further advantages, Dr. Friedman says. There is no breast compression or radiation involved in the procedure and because MR can assist in the detection of almost all lesions, it comforts patients when MR results show no evidence of a mass.

 

"While it is disconcerting when cancer is found, MR helps patients make more informed treatment decisions," he says. "For example, they might choose a lumpectomy versus a mastectomy, because of the increased confidence with MR evaluation that all of the suspicious tissue will be detected. With the growing prevalence of breast MR, the center is receiving requests for the procedure from some high-risk patients."

 

Breast MR is also a major leap forward for women with BRCA1 or BRCA2 genes. Many of these women choose to have mastectomy and/or oopherectomy surgeries to reduce their chance of developing cancer. Because of the sensitivity of breast MR, Saint Barnabas can offer these patients MR surveillance as an alternative to invasive surgeries. "Pre-operative MR helps to determine the best surgical approach and identify additional lesions that weren't detected with other tests."

Breakthrough technology: the future of breast MR

In the near future, Saint Barnabas will obtain a core biopsy machine for breast MR, which will provide additional diagnostic information and help patients avoid unnecessary surgeries.

 

In addition, to further address specificity issues, Saint Barnabas is involved in breast MR research and will be investigating MR Elastography, a new method that has the potential to measure tissue elasticity, currently under evaluation at Philips. The procedure employs a mechanical wave generator to create a gentle vibration in breast tissue. MR may be used to track the waveform and determine how the tissue reacts to motion; whether it appears stiff or loose. Preliminary studies have shown that cancerous lesions are associated with stiffer tissue. Investigators theorize that MR Elastography may be combined with other imaging information to help assess tissue.

 

 

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Best Practice
Achieva 1.5T, Intera 1.5T
Release 9
Body, Breast, Oncology, Women's health
 

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