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Boca Radiology Group

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Breast MRI Cases

Boca Radiology Group is pleased to offer state of the art services in breast MRI.  We use a dedicated high signal to noise breast coil on our 1.5 Tesla magnets. Our protocol combines high bilateral spatial resolution (3D gradient echo with 512 matrix and 2mm slices of both breasts) with multiple acquisition time points to evaluate the kinetics of tissue enhancement following dynamic bolus gadolinium administration. Pathologic tissues can be identified by their morphology (shape and solid/cystic nature) as well as by their vascularity and permeability (kinetics).  Special post processing software provided by our partner in breast MRI research, Mevis Technologies has been moved to a more user friendly Windows 2000 Professional interface  (DynaCAD™) from the Silicon Graphics platform. This allows rapid evaluation of large breast MRI data sets in 1- 2 minutes with full 4-Dimensional display (3 orthogonal spatial plus time dimensions with color encoding of enhancement curves) as well as automated 3D motion correction (DYNA Motion) and 3D MIP color overlay (Dyna MIP).

We have conducted a prospective clinical trial of breast MRI's ability to stage breast cancer in collaboration with the Weizmann Institute in Israel and Mevis in Bremen, Germany.  We have found that MRI of the breast allows more accurate staging of the extent of breast cancer than mammography and ultrasound.  Our post-processing techniques yield higher sensitivity and specificity than interpretation of the raw image data alone. Patient management is significantly changed in many cases.  For example, detection of more extensive disease in the breast of concern often leads to mastectomy rather than lumpectomy and cancerous lesions in the opposite breast are often discovered.

We are also evaluating newer software applications including 3D motion correction (DYNA Motion), 3D MIP color overlay (Dyna MIP) with our partner Mevis Technologies.

<click here to download a 3 minute video (24MB, wmv format) demonstrating MRI-guided breast biopsy>

Clinical cases:

Case 1

This 61 year old female presented with a dominant mass in the right breast with several other indeterminate lesions seen on mammography.

Mammography CC view demonstrates three masses in the right breast, one behind the nipple and two others in its medial portion.

MRI magnification maximum intensity projection (MIP) view of right breast demonstrates the same three masses with tumor bridging between them and extending toward the chest wall.

MRI T2 axial slice indicates cystic nature of subareolar mass.

MRI subtraction and color images show rim enhancement around cystic mass.

MRI image of color map of enhancement curves (kinetics of breast tissue) show intense early enhancement and rapid signal loss from the dominant mass (typical malignant characteristics).

Enhancement curve from dominant mass.

Final Pathology at mastectomy confirmed that the dominant mass represented infiltrating carcinoma with extension of intraductal carcinoma.  The subareolar cystic mass represented encysted papillary carcinoma.

Case 2

This second 61 year old female presented with micorcalcifications on mammography.

Mammography CC view demonstrates a circled suspicious area of microcalcifications in the left breast which are better demonstrated on the magnification view.

Post-processed color parametric map image demonstrates a large area of malignant enhancement in the central left breast.

These findings indicated a much more extensive area of malignancy to the breast surgeon which allowed accurate pre-operative needle localization and subsequent segmental resection with negative margins. Image guided biopsy and surgical pathology specimen revealed extensive intraductal carcinoma (comedo, solid, and cribiform types) with extensive cancerization of lobules.  Two small foci of well differentiated infiltrating ductal carcinoma were also identified.

Case 3

This patient underwent mastectomy, radiation therapy, and subsequent breast reconstruction. On a follow up clinical examination, there was palpable thickening raising the question of recurrent cancer.  An MRI excluded recurrence.  The maximum intensity projection image demonstrates enhancing vessels while the color map image demonstrates normal arterial vascularity at the margins of the reconstruction.

Case 4

An example of an obvious cancer in the right breast with motion artifact resulting in a false eccentric malignant rim of enhancement.

The movie demonstrates a comparison of the original post-processed data set  (left hand images) using a rainbow color map with the most malignant enhancement demonstrated in red.  The motion corrected data set is on the right.  Note that the artifactual background areas of color have largely disappeared and that the tumor now shows symmetrical peripheral malignant enhancement.

Case 5

58 year old woman with indeterminant calcifications central right breast. Fatty
Enbloc procedure: DCIS

MRI: biopsy cavity with 2cm enhancement posteriorly suspicious for invasive disease
Surgery: IDC, negative sentinel nodes

Points
MRI can better predict the extent of disease than mammography even in the fatty breast
Surgical management may change as a result of pre-operative MRI: sentinel node was performed preventing second surgery, wide localization performed appropriately to avoid positive margins


Case 6

The patient is a 69 year old woman presenting with a 2 cm left axillary mass found to be adenoCA compatible with breast primary. Negative prior mammogram
MRI identified 2 small suspicious masses in the UOQ


Diagnostic mammogram & US demonstrated 2 spiculated solid masses which corresponded
US core biopsy found 2 IDLC
Lumpectomy and axillary dissection was performed

Points
MRI is valuable in the evaluation of a patient with axillary disease with unknown breast primary
Targeted mammography and US performed after MRI will often identify abnormalities which then can be biopsied with US or stereotactic guidance

Case 7

43 year old woman found to have calcifications on baseline preoperative mammogram
Stereotactic biopsy found IDC
MRI found 7 suspicious breast masses

 


Bilateral mastectomy with reconstruction was performed

Points
Mammography may underestimate the extent of disease which is easily detected on MRI
The patient may be prevented from developing recurrent disease with preoperative MRI