In this physician presentation, Dr. Emily Ambinder, breast imager, explains the common uses for a breast MRI and novel insights when ordering this type of exam.
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https://www.hopkinsmedicine.org/imaging/provider-information/index.html My name is Emily Ambinder, and I am an assistant professor in radiology in the breast imaging division at Johns Hopkins. I served as the assistant division chief and the director of education for our breast imaging group. I want to start by thanking you for this opportunity to present today. I'm really looking forward to sharing information on rest. Memorize what referring providers should know. I have no disclosures. I think the most important thing for referring providers to know about Breast and Marie is when it is appropriate for your patients to get one. I'm going to spend most of the presentation going over the indications for Breast and Marie and showing examples of how Emery's can change clinical management. Next, I will briefly explain memory guided breast biopsies by walking through a case, and I'll discuss a few research areas in Breast Emery, the American College of Radiology provides appropriate indications for breast em arise. These include high risk screening evaluation of incentive disease in a patient with recently diagnosed breast cancer, additional evaluation of suspicious clinical or image ING findings and silicone implant integrity. I'm going to start by talking about high risk screening. Memory improves breast cancer detection that is a cult on mammogram and ultrasound. We currently recommend high risk screening Emory in women who have over a 20% lifetime risk of breast cancer based on risk assessment models. This would include patients with a strong family history of breast cancer. Ah, genetic mutation that puts them at high risk for breast cancer, such as a Bracha one or two mutation and patients who have had mantle radiation for Hodgkin's lymphoma. Our goal with high risk screening Emery is the same as our goal of screening mammography, which is to detect breast cancer as early as possible when we know it's treatable. This is our first case off a patient presenting for, ah, high risk screening. Emery. This patient had had right sided breast cancer. The, um, images flip. This is how the images always are in breast imaging, with e left side of the screen representing the right breast. You can see the patient has had a mastectomy, and that's why that breast looks so black in the left breast. The arrow is pointing to a new nine millimeter enhancing mass. This is very small. We were able to do a biopsy of this spot and found that this represents an invasive ductal carcinoma. This is, Ah, similar history. Another patient who had had a history of right sided breast cancer. Her cancer had been treated with a lumpectomy on her high risk screening breast. Emery. We found a small mass she didn't see at the anterior aspect of the breast, and additionally, non mass enhancement extending posterior really from that mass biopsy demonstrated invasive ductal carcinoma with associative DCs. The second category of Indication for Breast Emery is to evaluate extensive disease in patients who have recently been diagnosed with breast cancer. We know from multiple studies that additional sites of disease on a breast Emory in a patient with recently diagnosed breast cancer is about 15% in the IPSA lateral breast and 5% in the contra lateral breast breast. Emery can also provide important information for whether there's muscular invasion, which is really critical for surgical planning. We also do Preston Marai in patients who have had a lumpectomy with positive margins to help the surgeon determine where the residual cancer might be and help to guide their surgery. Finally, in patients who received new adjuvant chemotherapy, we'll do a breast. Marie to evaluate treatment response. This is a patient with a recently diagnosed right sided breast cancer. You can appreciate the large mass in the center of the right breast. On her emery. There is additional non mass enhancement extending posterior lee from the mast towards the chest wall and also anterior lee from the Mass towards the nipple. And this plays an important role in the patient's surgical planning. This is a patient who had a recent diagnosis of a left sided breast cancer. There is a speculated mass in the upper outer quadrant of the left breast. The arrow is pointing thio, an abnormal appearance of the pectoral ISS muscle, which is irregular and has enhancement. This is highly suspicious for muscle invasion. In this affected the patient's surgical planning. This is a really a dramatic example of a patient who has a very large amount of breast cancer in her right breast. You see, this conglomerate of Mass is taking up most of the right breast on the image to the left. She also has skin thickening. The image on the right shows enlarged, abnormal appearing lymph nodes. This patient had biopsy proven breast cancer in the breast and also axillary added apathy. This was a triple negative breast cancer, and the patient went on to receive neo adjuvant chemotherapy. This is really a dramatic response to that neo adjuvant chemotherapy, these two images air taken at the same slices as I showed on the prior slide. You could see almost complete resolution of enhancement in the right breast, where we saw that large conglomerate of enhancing masses on the prior image in the image to the right, centered at the right x ella. Those enlarge lymph nodes that we saw on the prior study are no longer seen. There are a couple of very small, normal looking lymph nodes, and this just really highlights how well some patients do with neo adjuvant chemotherapy. And we are able to provide that information to the medical oncologists and surgeons. The next category of indications for breast m r. I are additional evaluation of clinical or image ING findings. This is an uncommon reason for Emory, but something that we do see, we would always start with a mammogram and ultrasound. In these cases, there are some specific situations when there is a really high concern for a cancer in the mammogram and ultrasound are negative When we would recommend an Emory. These include a suspected recurrence, metastatic disease with a suspected breast origin and suspicious nipple discharge. This is Anne Marie from a patient who had a suspicious right nipple discharge in a negative mammogram and ultrasound on her Emery. We saw a very small mass in the slightly medial right breast at the anterior depth. We also saw extensive linear non mass enhancement extending all the way from the nipple back to the chest wall. This patient had a to cite emery guided by FC with biopsy of the mass in the interior breast, as well as the most posterior aspect of the non mass enhancement. In order to define the full extent of her disease, the anterior mass demonstrated invasive mammary carcinoma in the posterior non mass enhancement demonstrated D C. I. S. The station proceeded to have a mastectomy due to the large area of disease found in her breast. This is a patient who had had a history of a right sided breast cancer with a deep flap reconstruction. She had a suspected recurrence. And unfortunately, on her emery, we saw thes two new enhancing masses in the reconstructed right breast. These were subsequently biopsied and did demonstrate invasive ductal carcinoma, which had been the same as her primary diagnosis. The final indication for a breast and Marie is to evaluate silicone implant integrity. I have shown here the A C R appropriateness criteria, which lists Emery without contrast, as an appropriate test for woman in all age groups in women ages 30 to 39/40 Mammogram and ultrasound er also potentially appropriate. But Marie is appropriate for all of the's groups. I also want to point out that these memories air done without intravenous contrast, which is in contrast to the other indications that I talked about which all recommend Marie Brassed. With intravenous contrast, the FDA also recommends routine screening for rupture three years after silicone implant placement and every two years thereafter. I just want Thio briefly discussed What I mean, what I'm talking about. A silicone implant rupture When a silicone implant is placed in the breast, it has an implant wall which holds the silicone in place. The body forms of fibrous capsule around the implant wall within inter capsule there rupture the implant wall breaks and we can see that implant wall within the silicone implant itself. The fibrous capsule remains intact with an extra capsule rupture. There is a break in the fibrous capsule allowing silicone to escape from the silicone implant into the surrounding breast tissue. In orderto have an extra capsule rupture. You were required to also have an inter capsule er rupture. This is the appearance of a normal silicone implant on mammography. The bright white areas are the silicone implants. You can imagine that it would be impossible to see the implant wall within these implants because they're so bright. Um, mammography, we are able to see extra capsule er rupture. As shown in this example, you can see this bright white silicone extending outside of the implant capsule. The benefit of Breast Emery is that we're able to identify inter capsule rupture. This is a great example of a sagittal image of an inter capsule, er silicone implant rupture. We have several signs and breast imaging that we look for, including the Linguini. Sign the keyhole, sign the cheer drop sign. In this example, you can actually see all of these signs within this breast implant We always want to confirm that we see the rupture on both sagittal and axial images. This is that same patient. The axial projection again demonstrates the inter capsule er, right breast silicone implant rapture. The left silicone implant appears to be intact on this image. Mhm e. Just want to just show this image to explain how the patient is positioned when they're having a breast Marie procedure. The patient is in the prone position, and we have a special to device that has very specific positioning for the breasts when a patient has a breast Marie biopsy there in this same position. But the breast is in a tight compassion so that we're able to do a procedure without the breast moving. Emery Guided breast procedures are on. Lee performed when the suspicious signing is a cult on both mammogram and ultrasound. We would always prefer to do the biopsy with mammogram and ultrasound because they are typically more comfortable for the patient. I'm just going thio, walk through a case of an Emory guided by FC to show how these are done. This is a patient with a recently diagnosed left sided breast cancer. The image on the left side of the screen shows the biopsy proven breast cancer in the outer left breast. The image on the right shows suspicious non mass enhancement, which is extending from that mass towards the nipple. This patient preferred to have a breast conserving therapy, and therefore we decided to do a biopsy of this non mass enhancement to help define the full extent of her disease. These are images from the day of biopsy. You can appreciate that the breast is in a slightly different shape, as it was on the prior exam, because on this study the breast is in compression again on the image. On the left, we see that mass, which represents the biopsy, proven breast cancer in the image. On the right, we see the linear non mass enhancement, which was indeterminant. After taking this first set of sequences, the patient is spot out of the Marie machine but is asked to stay as still as possible. We place a biopsied device into the area where we saw that suspicious non mass enhancement, and then we take another set of images, as you can see in the image to the left. The non mass enhancement is much more difficult to see. That's because it's been several minutes since that prior study, and the contrast has now washed out of that suspicious area and is seen throughout the breast tissue. We use landmarks and targeting to make sure that we're in the right position. The biopsy devices can be kind of hard to see, but it shone as a very dark straight line across the breast, as indicated by the arrow. After we check that we have appropriate positioning, the patient is again brought back out of the Emory machine but has asked to stay perfectly still. And then we take the samples. After we take samples, we do one more set of images, and that's shown in the image toothy right? As you can see, there is a dark black circle in the area where we had seen that non mass enhancement. This is susceptibility artifact from a combination of air and blood in the biopsy cavity, and that's exactly where we want the biopsy changes to be the result of this by FC Waas DCs, which allowed the surgeons thio, perform a larger lumpectomy and get all of the disease. In one surgery, the last topic that I'm going to speak about briefly are some topics and breast memory research in the three areas that I'm going to talk about our screening. Emery Diffusion weighted imaging in disparities in access to care. So the first topic that has a been having a lot of interest recently is understanding Who exactly, should be getting screaming breast memories, as I mentioned at the beginning of the talk. Currently, we recommend screening a Marie and women who have over a 20% lifetime risk of breast cancer. There have been several studies and other recommendations for women who have lower risk of breast cancer to also have screening rest. Emory's specifically, there were two large clinical trials showing that there was a benefit to supplemental Emery screening in women with extremely dense breast tissue. There's also evidence that women who are at higher than average risk but not at 20% lifetime risk. They also benefit in Emma right screening. Specifically, this would include patients who have a personal history of breast cancer or patients who have a personal history of a high risk lesion and dense breast tissue. One of the concerns with annual high risk screening memory is that we always used intravenous contrast for these study, um, studies. These are Catelyn, IAM based contrast agents, and there is not a lot of data on the long term effect of regular use of Catelyn. Iam. This is especially. This is something that we should especially think about in our patient population. Who, maybe getting a screening breast emery for 50 years. There's a lot of research in this topic of diffusion weighted memory, which would allow breast cancer screening without intravenous contrast. This has a lot of promise, but it has not reached clinical uh, has not been recommended to be used clinically yet. Finally, our group has a lot of interest in disparities and access to care. And we've done a lot of work looking at disparities in access to breast cancer screening, making sure the wording of our reports that go to the patients are at a level that everybody can understand. We also recognize that there are disparities and access to advanced breast imaging technologies such as breast emery, and this is something that we are always thinking about and trying to improve thes air. My references and I'd like to thank everyone for their attention and for giving me the chance to talk today. Thank you