 Hello and welcome to noon conferences hosted by MRI online. In response to the changes happening around the world right now in the shutting down of in person events, we have decided to provide free daily noon conferences to all radiologists worldwide. Today we are joined by Dr. Priscilla Slanitz as a practicing breast radiologist for over 20 years and over 175 published manuscripts. Dr. Slanitz currently serves as vice chair of academic affairs and associate residency program director in the department of radiology at Boston University Medical Center. A reminder that there will be time at the end of this hour for a Q&A session, please use the Q&A feature to ask all of these questions and we'll get to as many as we can before our time is up. We will also be using the polling feature today so be on the lookout for that. That being said thank you so much for joining us today Dr. Slanitz I will let you take it from here. Okay, thank you very much and thank you to everybody who's listening and has taken the time out of their busy day. I'm going to be talking a little bit today about breast MRI and particularly about how to look at lesions on MRI and how to approach the interpretation. So hopefully by the end of this presentation you'll have a good understanding of some of the logistics that are important if you're going to be performing breast MRI in your practice or if you're already performing it. And as I said we're going to focus most of our time on a systematic approach that you can use to analyze and interpret the imaging. Most of this will be based on the BIRADS Alexa con that has been created for breast MR interpretation and will be touching on all the different categories that are listed here below. So one of the most important things when you're going to be looking at breast MR images or performing them in your practice is that you need to be sure that you're using a dedicated breast coil. That dedicated breast coil will help you maximize your spatial resolution and these studies can be performed on a 1.5 Tesla or a 3 Tesla magnet depending upon what you have available at your facility. Another of the important things besides the dedicated breast coil is that if you particularly have premenopausal patients that are going to be having breast MRI, it's important to control for where they are in the menstrual cycle because in order to evaluate the breast parankama we're going to be giving intravenous gadolinium and the uptake of the gadolinium in just normal breast tissue will vary across the time in the menstrual cycle. So days 3 to 14 but ideally I usually say day 5 or day 7 to 10 are probably the best times to schedule your premenopausal patients for elective breast MRI studies because otherwise you may have a significant background uptake of the contrast making it difficult for you to see lesions and you may end up missing a finding. And this is just a good example of this patient here you can see has a lot of marked background enhancement. This is our kinetic map, which is a color coded map that will put blue on things that are less worrisome and red on areas that might be more worrisome but of course red is also in the heart here. But this patient we couldn't control for her menstrual cycle because it turns out this is actually an MRI in a patient who's currently lactating. And so lactational changes are kind of challenging with breast MRI and will certainly make it more difficult if you're trying to evaluate a patient who for example might have had a new diagnosis of cancer in the setting of lactation MRI the sensitivity may be somewhat lower. So another thing to keep in mind is the sequences that you're going to acquire when you're doing breast MRI. So the first thing to know at least in the United States, every institution performs breast MRI slightly differently. There is no standardization in the United States, the European countries have actually done a very good job at pretty much standardizing the sequences they obtain across multiple countries. And I think the lack of standardization in the United States presents part of a challenge for us because particularly if you're at a tertiary center where you're getting referrals in from other institutions or other practices. It can become very hard if you want to offer a second opinion on an MR study because of the lack of standardization and so most of us do not actually offer second opinions on outside breast MRIs. It's not that we won't look at them but we don't officially offer a report. So the typical sequences though that most people are using is a non fat suppressed T1 weighted image. There's often a T2 weighted image. Now sometimes there are facilities that use fat suppression on a T2 weighted image and others do a non fat suppressed T2 weighted sequence. And then there's always a dynamic sequence. Most often these days it's now acquired in the axial plane but there are facilities that still are doing sagittal acquisitions as well as coronal acquisitions in some circumstances. But this is usually a fat suppressed T1 weighted gradient echo sequence and you're typically administering the contrast and then acquiring three to five post contrast acquisitions so that you can look at the uptake of the contrast in the breast tissue and specifically in any particular area of concern over time. And then even though we use fat suppression for that sequence we do often provide subtraction of the pre contrast from the immediate post and usually the very delayed post contrast sequence. And then we'll look at the kinetic analysis usually using a software algorithm, which will then also be able to generate your maximum intensity projection. Now as I said in Europe they don't actually use fat suppression so they rely solely on the subtraction of the pre and the post contrast images to assess what's enhancing in the breast tissue. But there are even circumstances in here in the United States where the technologists who's performing a study can't get adequate fat suppression. And the one common time that this typically seems to happen is once a patient has a silicone implants in place. It becomes very difficult for the technologists often to get good fat suppression this homogeneous across both breasts. In that situation that's probably where I would recommend that we don't do fat suppression and that we acquire the dynamic sequence. In the absence of fat suppression. So we're using more of a European model for imaging and then we rely upon subtraction in order to look for areas of enhancement. Now of course if you're relying solely on subtraction one of the most important things is going to be positioning and making sure that the patient is comfortable. So positioning is critical one for minimizing artifacts so here was a patient who you can see clearly the right breast is very well positioned in the coil. But our left breast which is smaller seems to have these undulating folds along the lateral aspect because the breast hasn't adequately dropped into the coil itself. And in fact you start wondering what is this more focal area of enhancement, which seems to involve the skin. And so she got reposition and it turns out that was just the nipple being trapped because it was caught on and the patient was not adequately positioned. Adequate positioning is not just important for minimizing artifacts but it's also important because you want the patient to be able to hold still. And if they start moving in the middle of your study it also is going to make it more challenging for you to interpret the imaging. The other reason positioning is critical is that you want to have homogeneous fat suppression so you really do want to get both breasts in the coil and hanging in the prone position with them hanging sort of dependently and evenly. And this is one of the reasons why positioning is so critical is because if the patient's not comfortable they're going to move. So in this particular case in this 35 year old high risk moment you can see that I've actually put in the color maps for each of the dynamic sequences. So this was the first dynamic acquisition about a minute into after the injection, the second one, the third one and the fourth one. And you would believe that the color map here says that the edge of that implants enhancing in fact it has what it looks like washout. But then if you look by the time at the fourth sequence, you now can see that that has actually shifted a little bit laterally and posteriorly indicating there's actually been patient motion. And when you have significant patient motion your kinetic map which is going to be one of the characteristics that you're going to look at to help figure out whether or not you need to intervene on a finding is even going to become unreliable because motion is going to register as though there's been a change in the enhancement between the different sequences. Now what about other protocols so the standard protocol that I just sort of presented the patients usually on the scanner for somewhere between 15 to 25 to 30 minutes depending upon these specific sequences and the ability of your scanner. But there are some centers now that are offering what's called abbreviated or fast MRI. Now this technique was first developed in Germany by Christiana cool, and in her particular case she has patients that go through this abbreviated protocol and are on the scanner for less than five minutes. Now if you do the abbreviated protocol. Now what that entails is a pre contrast T one weighted in the United States a fat saturated image, you do a single post contrast acquisition, you then subtract those two, and you're not going to be getting any kinetics and a few centers actually also include a T two weighted image. The patient as I said is on the scanner probably for at most five minutes, maybe 10 at the most but it's usually under about five minutes or so or less. And so there are some advantages to this fast protocol in the sense that you can get many more patients through imaging. So you can increase your volume of clinical volume by using an abbreviated protocol, and at least the preliminary studies coming out indicate that this is pretty much as good as the full protocol for nearly all cases in terms of cancer detection. You can see centers doing ultra fast imaging where you're getting higher temporal and spatial resolution but this is not been very widely adopted at this point. Just to go back one other thing about the abbreviated protocol to keep in mind at least in the United States. There is no CPT code to bill for it. People are still using the standard CPT code, but I suspect given that the imagery time is so much less. And there are fewer images to review that eventually a CPT code that will be specific for the fast protocol may end up being developed. These centers that I know that are using at least in my area in which I live up in the Boston area are actually some of the patients are being charged to insurance, but some are also paying out of pocket a very nominal fee. So let's switch gears now and think a little bit about how we're going to interpret our images now that we've got high quality images. And we're going to want to use the Byraz lexicon. Byraz lexicon for MRI is comprised of these components. So one of it is breast density. There's going to be the background parankamal enhancement that you're going to want to comment upon. If there is a specific finding we're going to talk about the morphology of that finding. And then we're going to talk about the kinetics. The reason we have kinetics or we do that dynamic acquisition is that we're looking for lesions that have or leaky blood vessels because that is characteristic of what happens in malignancies. And so there will be different patterns on the kinetics that we will be looking for that are more or less associated with cancers. And then it's important we did as you recall mentioned that we get T1 and T2 pre contrast imaging and those signal characteristics of these lesions can sometimes be helpful in terms of honing your differential as you're putting together your report. So first let's start with breast density. So you can see breast density if you are a breast imager out there and have been reading mammography for many years. You can see that the tissue patterns or the density of the breast tissue is very comparable to the four categories that we use for mammography, almost entirely fat, scattered fiber glandular tissue, heterogeneous fiber glandular tissue or on a mammography that's heterogeneously dense and extreme fiber glandular tissue which we use as the extremely dense category. So this should be very translatable for anybody who's doing breast imaging on a regular basis. Then for MRI because we're giving contrast and we're looking at the uptake of the contrast over time, we want to look about or comment about the background parenchymal enhancement. Now you could look at the first pre contrast image to get a sense of how much background enhancement is there, or I tend to find that looking at the maximum intensity projection is the easiest because it gives you a really good sense of whether somebody has very minimal uptake of the contrast in the background tissue or very marked uptake, such as in this case where you can see there's really a lot of uptake in the breast tissue on both sides. And you want to also comment not just on the amount of uptake, but also whether it's symmetric or asymmetric. Most of us, if you have not had anything done to your breasts should have about the same amount of breast tissue on both sides. So the background uptake should be fairly symmetric, but there are some instances where it can be very asymmetric. Now this was an interesting case because here this was a younger woman I think she's in her mid 40s, and she had a known cancer so she was undergoing an MRI for disease extent or trying to figure out how much tumor she had because her breast tissue also was rather dense. And this is actually the known cancer and then you can also see it picked up another lesion in her medial breast. And these are actually the same, it's the same patient with her axial images. Here's our T2 way to sequence, the T1 pre-contrast, the immediate post, and then the delayed post. And you can see these two lesions, they look very different. This one has rim enhancement, it's irregular, it's got heterogeneous internal enhancement and kind of intermediate signal on T2. This is the known malignancy. And then there was this more slightly heterogeneously enhancing very well circumscribed mass in the medial breast, which turned out to be a fibratenoma. What was interesting though is it's very, very important that you correlate your imaging findings on MR with all the other more recent available breast imaging. Because it turns out in this patient with very marked background enhancement on her mammogram, she had at least two grouped areas of calcifications removed from the tumor itself, which is located here, marked by this BB. And so one of the things to keep in mind is that if there are still suspicious findings on mammography, especially if there is marked background enhancement, that you can't ignore those findings. And this patient underwent a stereotactic core biopsy of one of those grouped calcifications, and this actually came back as grade two ductal carcinoma in site two. So keep in mind, if you have an MRI that has marked background enhancement, the sensitivity to pick up lower grade lesions like ductal carcinoma in site two or even a low grade invasive malignancy may be diminished. So you need to have that correlation that you do to be sure that you don't overlook something that could change the management because for this patient it ended up changing her management from lumpectomy to a mastectomy. Now here's a patient, she's 48. And again, it's a for high risk screening but we can notice that there's really marked background enhancement on the right breast and really minimal if any enhancement on that left breast and so it's very asymmetric pattern of enhancement and you can see it also on the color map itself. So when you see asymmetric enhancement, one of the most important things is you really want to know what's going on clinically because the other thing you might have noticed is that her left breast looks smaller than the right now some of us are asymmetric, but you want to correlate with her history because it turns out that this patient has had a lumpectomy. And so she's also been treated with radiation therapy so one of the most common causes of asymmetric enhancement is going to be prior radiation therapy. The other things that can cause it is suppose the patient had had a autologous flap due to a breast reconstruction and she was status post mastectomy. Now we know she's not after a mastectomy here because you can see there's actually breast tissue here and she hasn't had a flap because most of those autologous flaps are filled with fat. But a breast reconstruction if she happened to have a myocutaneous flap could have also potentially given this appearance. Hormones, whether they're exogenous or endogenous their variabilities can sometimes cause asymmetric enhancement and then there can be malignancies, but when there's a malignancy, the enhancement that would be abnormal would be on the side of increased enhancement rather than decreased enhancement so correlation with your clinical history is going to be important. This is an example of a patient who's 29 she had a palpable lump. She actually had a biopsy that showed she had a cancer her notice her palpable lump so we tend to mark where they have a symptom, but you can see there's very marked enhancement on her left breast, sort of more mild to moderate on the right breast but clearly asymmetric and it turns out this is her side of abnormality and this is all a malignancy. This was grade three invasive ductile cancer. So in this case the asymmetric background enhancement is really not background enhancement it is actually the underlying malignancy that's infiltrated to her entire left breast. In this case I really do love because this was another patient who had a history of left breast cancer and you can see she's dramatically asymmetric. She had been treated with a lumpectomy and radiation therapy on the left and this was her in 2012. The subsequent year she was screened you can now see that asymmetric background enhancement has disappeared. But in 2014 the background enhancement reappears and it turns out that between 2012 and 2013 the patient went on to moxifen. And she went on it for a year and didn't tolerate it very well so between 2013 and 14 she came off to moxifen and so she had a reappearance of this marked background enhancement is called to moxifen rebound. So it's important to also know on patients whether or not they're taking any endocrine therapy because it will potentially end up to a third of patients alter the background paranormal enhancement. And that's true for both to moxifen as well as the aromatase inhibitors. So now let's talk a little bit about morphology. So the three things that we talk about on MRI are foci, non mass enhancement and masses. Now foci are less than five millimeters in size and they do not occupy space, like a true mass does, which has true borders and serve a butts the tissue or pushes out against the tissue. So a mass is very different than a focus. And then non mass enhancement is basically patchy areas of enhancement that doesn't necessarily conform to a space occupying lesion. And we'll talk a little bit more depth about each of these. So what about the foci. So in general a focus is thought to have less than 3% chance of malignancy. What's fascinating about foci is that if you look at the literature, the malignancy rate of a biopsy focus can be as high as 37%. So then you have to ask yourself, well, why is that the case? Well, it makes sense because although we make things something's a focus, how do we know it's not a small mass? I mean cancers grow and at some point they're going to be less than five millimeters in size. So my feeling is that if you have a solitary focus that possibly could be a small mass. And so if it's really truly solitary and looks different than the rest of what's in the background. And particularly this case we have a focus here, and it has read which means it has washout kinetics which is the most worrisome type of kinetics. So I think we need to actually intervene in biopsy that because those are probably more likely potentially to be malignancy than you know scattered foci that are throughout both breasts and have very similar kinetics. So I think we need to use some common sense here but I think the solitary foci are very challenging sometimes to be able to differentiate a focus from a small mass. So it turned out to be fat necrosis. So there are benign things that can present a solitary foci that are obviously not cancer. But in this particular case I think given that it was solitary and had suspicious kinetics, I think a biopsy was very indicated. Now if you have a mass, we're going to talk about the shape of the mass, the margin of the mass and the enhancement pattern. So masses can be somewhat round or oval, or they can be very irregular, like these two cases. The margin can be very circumscribed. So we have several circumscribed masses or can be not circumscribed, meaning that it's irregular or even speculated. And then the enhancement pattern can be homogeneous like it is here, heterogeneous, it can be rim enhancing, and it can have dark internal septations. And these different enhancement patterns and shapes and margins will bode more likely towards things that are benign versus malignant and we'll talk a little bit more about that as we go through some cases later on. With regard to non mass enhancement. So we talk about focal areas. So here's a focal area of non mass enhancement. We talk about linear ductile enhancement and linear ductile non mass enhancement actually has a very high association with malignancy. We have segmental non mass enhancement. And you can have some regional areas of enhancement and multiple regions and diffuse of non mass enhancement. Most of these are typically benign. And with non mass enhancement, just like with masses, we're going to talk about the internal enhancement pattern so it can be homogeneous, heterogeneous, some more homogeneous, slightly more heterogeneous, and then it can have this clumped or clustered ring appearance where you see little dots and sort of rim enhancing tiny areas within an area of clumped enhancement. The clustered ring or clumped pattern is actually more likely malignant. Finally, there's kinetics. So there are three curves that we predominantly talk about we talk about the type one curve, which is progressive or persistent those are two terms that people use kind of together. So they pretty much is the type one curve and you can see that although it's less likely to be associated malignancy, there are cancers that do present what they type one pattern, meaning that it has rapid uptake in the first minute, and then it just slowly holds on and sort of traps a little bit more contrast over time. Versus the type three curve, which is what we call as the washout curve or delayed washout, and you can see it has a much higher association with malignancies. It typically has rapid uptake and then over time it actually loses some of that contrast you can also see the slope of that uptake is much steeper than with the persistent or progressive curve. And then many of the malignancies fall into the type two or we call the plateau curve where there's rapid uptake, and it just kind of holds on and stay steady state over time. There's plenty of obviously benign lesions that can actually demonstrate washout kinetics so I've seen fibroidenomas I've seen fat necrosis lymph nodes typically show a type three kinetic curve as well. Finally, the T two characteristics so you can use the appearance on the T two sequence to help sometimes sort out whether or not you have something to be concerned about. Most lesions that have increased signal on a T two weighted sequence are going to be benign because they're water or fat containing. So typically cysts lymph nodes here's a small lymph node with a little rim and a fatty center. So that if you see things that have increased T two signal majority of the time they will be benign. There are a few exceptions though and this is one of the examples down below here is a very T two bright mass. But you can see on the post contrast images there's rim enhancement as well as a focal nodular area of enhancement. And this was actually a mucinous malignancy. The other cancers that can be T two bright or necrotic malignancies but again it's not just the T two signal on itself you have to combine it with the other characteristics that you see of the lesion on the other sequences. If you have decreased T two signal now that's another story because that is seen more often in malignancies. But it also can be seen in other processes where there's a lot of dense fibers tissue such as in a post lumpectomy bed or post surgical benign biopsy bed. But typically dark signal on T two especially in this particular case where it's a little speculated mass is concerning for cancer. T one signal can also be helpful so if you have increased T one signal. Which you'll be best appreciated on the T one pre contrast image such as here you can see there's all this increased signal in a ductile distribution and there's no enhancement in those ducks on the post contrast except for a lot of background enhancement here. This will indicate a benign process and this is just protonaceous or hemorrhagic debris within a ductile system. So now we're going to go on to some cases and a few of these will become interactive and we'll have some polls as we go along. So the first case we're going to present is this 42 year old patient. They're high risk so we do a lot of high risk screening here in Boston because they happen to have a high population of people that either have strong family history or they actually are known BRCA one or two mutation carriers. So this high risk woman came in for her routine MR and here in the sagittal plane you can see there's a little you know focal mass here that demonstrates some enhancement based on the enhancement curve this demonstrated a wash out. And the other thing to notice is on the T two signal right in the area of this mass there's some T two bright areas. And so here's our first poll in this 42 year old woman who has a T two bright enhancing mass in the left breast and sort of in the central inner breast with type three kinetics that means the wash out. What is your best next step. Is it to recommend a comparison to the recent mammogram recommend a second look ultrasound recommended MR guided core biopsy. Or do you want to recommend a six month follow up breast MRI. Okay, so interestingly, about a third of you would compare to the mammogram a third would do second look ultrasound. Another third would do MR guided core biopsy and most of you decided well I don't want to follow it although a small minority one to follow it. So the T two bright signal makes you think okay could be benign. But I think you know the wash out connects doesn't worry you so I can see why people chose the MR guided core biopsy as an option. Second look ultrasound this is a five millimeter mass you might see it you might not. I think the first step and the answer that you know there's always you know one best answer would be to compare to the most recent mammogram. I say that remember this mass is media because you're seeing the ribs here so there's a mass in the sort of central media breast and it turns out. The prior year she had been called back to evaluate this mass right in the posterior medial central breast. And we actually already knew that she had an area of what is called apricon metaplasia in this area. You know I saw a coic mass with microcystic areas. And so this was actually just apricon metaplasia. And even though it had type three kinetics it did not need to be biopsied. And so I think the most important thing is you really do want to correlate with other modalities. And also keep in mind it's been actually quite interesting a number of years ago I looked at our benign biopsy results from our MR biopsies at my facility. Nearly 50% of the time it was apricon metaplasia. So apricon metaplasia which is a variant of fibrocystic change is a very common false positive diagnosis and had we looked at the T2 weighted sequence more closely we might have avoided some of those biopsies. Here's another case of 44 year old screening MR. There's multiple T2 bright lesions. They're hypo intense on T1. And they don't enhance because here's the subtraction. The other interesting thing is you can see there's a T2 dark lesion here. That's very T1 bright. And that also doesn't really enhance as well. And so T2 bright lesions or T1 dark or T1 bright masses with no enhancement. This is all just consistent with fibrocystic changes. Sometimes you'll see a rim of enhancement around one of these lesions. But those typically are still benign. And this is just a good example of another patient 49 who's high risk. She had this T2 slightly bright but really kind of more intermediate signal mass that was bright on the T1. And you can see on the subtraction there's actually a nice thin rim of enhancement around the central area that's not enhancing. So this is actually consistent with a protonaceous cyst that is probably slightly inflamed. If there's ever a question, you could go on to ultrasound to prove it. But generally, if I don't see any enhancement centrally and I've got a thin rim of very concentric enhancement, that's easy to call as an inflamed protonaceous cyst. But you do have to be careful because I show this case because it's very easy just to kind of say, oh, there's a rim of enhancement around something that's T2 bright. It's got to be a cyst and it's inflamed because here's this case here in 2008, this patient was undergoing multiple MRs every year or so. And she had a little T2 bright mass here. Look like there was a rim of enhancement. So it was called an inflamed cyst. The next year, right in an area where she was now feeling a lump, there's a little T2 bright thing. And lo and behold, we see that the rim of enhancement now looks thicker. And I would argue there are now like little speculations potentially, but nobody made much of that and they just called it an inflamed cyst. So she came back in 2011, we changed our protocol now from sagittal axial. You can still see there's T2 bright signal. But now the rim enhancement is actually somewhat eccentric. There's very little enhancement on this side. And by 2012, we finally got smart enough because all of a sudden there's very little T2 bright signal. So increase in the T2 dark signal here now. And now we have this homogeneous area of confluent enhancement. And this ended up being a invasive ductal cancer grade one. So when you're going to call something an inflamed cyst, make sure your rim enhancement is smooth and symmetric around the entire cyst, because any irregularity or eccentricity really should prompt further imaging or possibly even intervention. So this patient ultimately had a second look ultrasound. We found a very classic hypoechoic irregular mass. And this was biopsy confirmed to be a grade one cancer. Okay, moving on to our next case. Here we have a 50 year old one. Also high risk. You can see that there's a pretty well circumscribed mass here. We have a fairly nice enhancement. Looks like it has these thin dark internal septations. Here's the mass on the T2 sequence. It looks predominantly T2 bright. And it looks like it has this very slow sloping curve of type one or persistent kinetics. So here's our second poll. So you have this 50 year old woman. The next step is to recommend a yearly breast MRI. Recommend a second look ultrasound. Recommend MR guided core biopsy. Or recommend surgical excision. Okay. So it looks like a majority of people wanted to investigate this to do a second look ultrasound. A third of you wanted to do yearly breast MRI. So we're pretty much split between those and a smaller minority wanted to biopsy or do surgical excision. So some form of biopsy was really a minority of you. And so what is it about this mass that's a looks very benign. So the fact that it's T2 bright. Helps. And the fact that it has not an enhancing internal septation. And third, the kinetics was type one or progressive. So those are all features that would favor that this is benign. And so I would favor that you actually can just. Have a yearly breast MRI. If you're really confident that these are non enhancing internal septations. Cause this would be consistent with a fibradanoma. When you're not as confident, which I show you this case, because is this one really a fibradanoma? So you could argue this looks sort of similar to the case. I just showed you, it looks like there could be not enhancing internal septations. But I would argue if there's any question, just like you, those who were pulled in the back. They said that some of you wanted to do second look ultrasound. How do I know these are not enhancing internal septations versus heterogeneous internal enhancement. So the difference on this particular case is, let's look at the T2. We don't see a clear T2 increased signal in that comparable area. And instead, it almost looks like on at least on the axial plane. This is more like heterogeneous enhancement. And therefore. For this particular case, I would definitely want to recommend biopsy. And this actually turned out to be fat necrosis. So it was not a malignancy, but this one I did not feel as confident that there were not enhancing internal septations as well as the fact, partly because there's not. A defined area of T2 increased signal. How about this case of 34 year old? She has a palpable, tender, right breast lump. She had to work up with a negative mammogram and an ultrasound. And because her symptoms were really quite impressive. Her exam was so impressive. Her referring provider. And the radiologist thought that she might benefit from MRI. So here's her example. And here's a marker over what she's feeling. And even on the maximum intensity projection, there's a subtle faint area of enhancement in that vicinity. You can see it here on the sagittal reconstruction. And here's other sequences that you can see on the subtraction, clearly in the area that she's feeling, there is some focal enhancement. But notice that there is some focal enhancement. So it doesn't even meet our criteria for enhancement on the kinetic map. The other thing that was interesting in her is that on the T2, it looks like the tissue, all of the tissue in that area that she's feeling the lump. Has increased signals, not very defined. It's a large area of tissue with increased T2 signal relative to the opposite breast. So what about this one? What are you going to do with this woman? She's 34. She has a patchy area of enhancement with below threshold kinetics. It corresponds to what she's feeling. What is the next best step? Are you going to reassure the patient that the findings benign? Are you going to recommend a second look ultrasound? Are you going to recommend an MRI? Or are you going to recommend surgical excision? Okay. So. I mean, I mentioned that if it's below threshold, likely it's going to be benign. So that's, I can see why people would choose that. Recommend second look ultrasound. We had done an ultrasound already in this area. So we're going to recommend a second look ultrasound. Are you going to recommend a second look ultrasound? Are you going to recommend a second look ultrasound? Are you going to recommend a second look ultrasound? Are you going to recommend a second look ultrasound? Are you going to recommend a second look ultrasound? Are you going to recommend a second look ultrasound? I had done an ultrasound already in this area. I guess you could look again, but there really wasn't anything on the first ultrasound. And we had looked pretty extensively because the finding on exam was so concerning. And then another third of you thought we would do an MR. Got a core biopsy. And I would argue we ended up doing the MR. Got a core biopsy. Recognizing that it was more likely going to be benign. Cause it really had no features. Of malignancy. And I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. And her exam was very impressive. So we ended up doing that. And it turned out to be lymphocytic mastopathy or diabetic mastopathy is what people used to call it. Which is a benign entity, but at least it then gave the patient an answer to what she was feeling. And it explained why it felt that so firm on physical exam. So keep in mind that lesions with below threshold kinetics or malignancies that will have below threshold kinetics, such as low grade DCIS, as well as even a low grade invasive lobular cancer can sometimes, and there's a few, I've seen one, I think low grade invasive ductile cancer that had below threshold kinetics, but a majority of lesions with below threshold kinetics are going to be benign. And based on the literature, this below threshold or even lack of enhancement has a negative predictive value of 93 to 100%. If your mass has a smoother lobular margin, again, very high negative predictive value. If you can confidently call those non enhancing internal septations, again, very, very high negative predictive value. And T2 bright lesions in general have a very high likelihood of being benign. But of course, if they're a regular or speculated or show rim enhancement or nodular enhancement, that's where they become somewhat suspicious. What about this 48 year old? She's had a reduction mammoplasty and then came for screening MR. So here's her mammogram. You can see some classic changes from the reduction, kind of a swirling pattern. There is more of a confluent patch of tissue up here superiorly. There's all these course benign appearing calcifications related to the reduction. And here's our MR T2 pre and post. And you can see there's a more focal area of enhancement corresponding to that more focal island of tissue on the mammogram. And within it, you can see there's non enhancing areas that look like they're comprised of fat because they're following fat signal on the T2 weighted image, as well as on the pre contrast where they're saturating out like the other fat in the breast. So this is actually just a fat necrosis, which would be an expected finding in somebody who's had a reduction mammoplasty. Here's another patient who's 42. Here on the T2 weighted, you can see there's a small mass here. It has a darker rim and sort of a higher signal center. And it has this mixed kinetic pattern on the kinetic map. And you could correlate this with her mammogram because she's pretty fatty. And I bet you would see this, but this is just an intramammary lymph node. And to keep in mind that intramammary lymph nodes often will have this type three or wash out kinetics. So it's not that you need to biopsy every lesion that has suspicious kinetics because you really need to correlate it with other features that you're seeing on the sequences. Here's another patient, high risk woman. She had a screening MR. And here she had some background sort of scattered enhancements and foci potentially. Here's one that sort of stood out a little bit. And the question is, is this focus concerning it had a progressive kinetics? So she's high risk. She has a solitary focus. It has progressive kinetics. What would be your next best step? Should you do a six month follow up MRI? Do you do a yearly MRI? A second look ultrasound? Or do you want to do an MR guided core biopsy? So she's high risk with a solitary focus. Have progressive kinetics. So not as worrisome as some. What do you think you want to do? Okay, so a third of you want to follow it. About a third want to biopsy it. And the others are kind of split between the other two. And I think, you know, this is, this is a tough one because the progressive kinetics is less concerning, but it really is a solitary focus. So then the question becomes, do you think it's a mass or not? If you think it's a mass or if you're worried about her high risk status, I think MR guided core biopsy would probably be preferable, but I don't think you're completely wrong. If you want to follow it in six months and we'll talk a little bit more about that as we get to this next slide. We actually ended up doing a biopsy on this and it turned out to be a low grade invasive ductile cancer. How about this patient? She has mild background enhancement, some scattered foci. Here's one focus that stands out a bit more. It has a correlate on the kinetic map. Progressive with a dot of plateau centrally. Has a type one curve. But notice on the T2 weighted sequence right in that area, it looks T2 dark. So this was actually biopsy because we felt that this was less likely a focus. And even if it was a focus, it looked very different than the other foci that were scattered in the tissue. And this turned out to be a tubular carcinoma. So this is a tubular carcinoma. Here's another patient who had right nipple discharge. So on the T1 pre, you can see that there's this T1 increase signal in a ductile. Distribution. So this is a duct with bright material within it. So either prognosis or hemorrhagic debris. And then on the post contrast, you can still see the T1 bright signal. And on the subtraction, you now notice that there's a little bit of nipple discharging in the duct. That's not enhancing that you now can appreciate it and sitting right here. So this was biopsy. Excuse me. And turned out to be a papilloma. And that would be probably the most likely thing in the setting of a patient with nipple discharge. So again, a solitary focus that has suspicious morphology or kinetics really should be biopsy. So, but all of these three cases really show that it sometimes is very difficult to differentiate a focus from a small mass. So how do I do that? So, I mean, I try very hard to ask these following questions. Do I think that's enhancing lesion has borders? That is, is it a space occupying lesion? And does it look different than the other foci? The other thing I ask is, do I see a correlate on the T2 weighted sequence? And if I do, is it increased in signal or is it decreased in signal? Decrease signal and intensity would make me a little more concerned. And then I also look at the kinetics. What are the kinetics? If it's below threshold, I get less concern, but if it, even if it's type one, it doesn't necessarily help me that much. But if I think it's a mass, then I tend to go ahead and biopsy these to make sure that it's not a malignancy. And this is another good example of a 54 year old who had this focus. Somebody described it and they did decide to do a follow up. Actually, they called it benign. There were other foci that thought were similar enough, but on follow up, you can see a year later, it actually had gotten bigger. And so this turned out to be an invasive ductal cancer. And so enlarging foci, particularly in patients who are at high risk for breast cancer and our undergoing annual MR for screening, any enlarging focus in that population really should be biopsied. And this is based upon a relatively recent study where they had 166 high risk women. And they looked at how often do they actually have foci. And it was interesting that about a third of them had foci. And it was more often in people that had dense tissue or moderate and marked background enhancement. And of those 35%, 3% enlarged on follow up imaging. And in those that enlarged all of them were cancer. So pay it close attention to foci when you see them in that high risk patient, because if they do grow or enlarge, they could actually be a small cancer. Here's another patient, 38 year old. Also high risk. And you can see what she has is a focal area of non mass enhancement with progressive kinetics. Nothing else in the breast really enhanced. So what would you do with this patient? She's 38. It has focal linear non mass enhancement type one kinetics. What would you do a six month follow up MR, a second look ultrasound with biopsy, MR guided core biopsy or surgical excision. Okay. So majority wanted to do a follow up in six months. And a third wanted to do biopsy. And a couple were going to try to look with second look ultrasound. So this turned out to be DCIS. And what you need to keep in mind is focal non mass enhancement specific to particularly this linear form. It doesn't really matter what your kinetics are. The fact that it's there is actually very concerning because up to about a quarter of these will actually be DCIS or an invasive lobular cancer. So this is the one time where you really probably should go and do a biopsy. You could try to see this under a second look ultrasound, but it could be very, very challenging to find. And therefore most of us would actually just do an MR guided core biopsy as a result. And follow up is not optimal because of the high incidence of DCIS or lobular cancers in this particular kind of presentation. Here's another patient, 42 year old. She's high risk. She has this irregular enhancing mass, very homogeneous enhancement, sort of more intermediate signal on T2. And so because it had suspicious morphology, we went ahead and biopsy that, but it turned out to be a fibratenoma. So any focal mass, if it has suspicious morphology, probably warrants biopsy, unless you can explain it due to recent trauma or surgery, because you need to rule out that there's not a malignancy. Here's another case. There's a mass here enhancing. This got T2 dark. It looks speculated. It has a heterogeneous enhancement and mixed kinetics with both wash out progressive and a tiny dotted plateau. And so this was a grade two invasive ductile cancer. And so the features very typical of malignancy will be a T2 dark speculated mass and we'll have type three kinetics. What about this 45 year old high risk screener? She has a T2 dark, T1 bright, relatively circumscribed mass that has faint enhancement, probably type one. It was sort of progressive, but barely, barely above threshold, but the T2 dark would make you worry that it's possibly cancer. T1 bright tells you that maybe it's benign. So we went ahead and biopsy this and it turned out to be pseudo angiometous stromal hyperplasia or PASH, which is a benign entity. But I think when you have a mass that has mixed imaging features, it's best to exclude malignancy and pursue it with biopsy. And another case here is the 76 year old who actually presented with a left axillary lump. Here we have a very dense mass up in the axilla. We did the ultrasound and it was very heterogeneous looking, not classic for anything that I've seen in the axilla. I was very baffled by this case personally. It looked quite unusual, but it had a lot of internal vascularity. So prior to biopsy, we decided that we would go to MR to get better characterization. And what we saw in the MR was a very vascular enhancing area that corresponded to the mass on the mammogram. It has some T2 bright areas within it. So we were concerned that maybe this could be a necrotic malignancy with the T2 bright areas. And so then we subsequently went on and biopsy this, and this actually turned out to be an MAI or mycobacterium avium intracellular infection. And so it was not actually a malignancy in the end. So keep in mind when you see that increased T2 signal in the mass, always think about infection and inflammatory diseases as well as malignancy because it doesn't necessarily always have to be the necrotic tumor. So when you have a complex mass in the axilla, it really has a broader differential. This case was also fascinating. A 33 year old had a history of a right lumpectomy when she was 29 and now had high risk screening. And what we noticed on this maximum intensity projection was a very asymmetric enhancement of her left nipple, a real region compared to the right. And on the other images that I'm showing you here, you can see that this enhancement looks kind of very irregular and nodular. So the shape of the nipple on that left side is not at all like the one on the right. So it looks more like it's focal nodular enhancement. And then on the subtractions, you can appreciate there's this linear non mass enhancement sort of in a ductile distribution heading back here more posteriorly. On the kinetic map, though, this was all below threshold. So there was no above threshold kinetics, even involving this nipple, very asymmetric and nodular nipple enhancement. Here's the kinetic map here you can see. So what would you guys do in this patient? What do you think the most likely diagnosis would be? She's a breast cancer survivor. She has this asymmetric nipple enhancement as well as ductile non mass enhancement with below threshold kinetics. Do you think this is ductic Tasia, mastitis, papillomatosis or pageant's disease? Okay, great job. So majority of you almost 60% believe it's pageant's disease with a few choosing a few of the other entities. So this actually is her mammogram. And what was interesting on her mammogram, she had developed a few faint linear calcifications right in the area of the MR finding. You can see them here posteriorly and here more anteriorly. And this was high grade DCIS in the setting of pageants. So asymmetric irregular and nodular nipple or real enhancement is very worrisome for pageant's disease. Normally the nipple can enhance and it can be asymmetric, but it will maintain the shape of a nipple if it is just normal enhancement on MRI. And finally, just to conclude, I want to talk just a few minutes about sort of the outcome parameters in your practice. So if you're going to be doing a lot of breast MRI in practice, there are a couple of goals to keep in mind. So most importantly, we don't want to have a lot of by reds three assessments, meaning that we're going to be recommending short interval follow up in these patients. MRI studies are expensive and we really need to be a little more definitive. So you don't want to have more than 10 to 20% of your cases falling into this category. And ideally it'd be even greater if you could have it less than 10%. The positive biopsy rate is also something for you to pay attention to. So it really should be somewhere between 20 to 40%. But some practices actually have reported a positive biopsy rate up to 60%. I personally think that's a little on the high side, but you know, you need to at least be above 20% and ideally more probably in the 30 to 40% range. And then if you're going to biopsy something, when do you do MR guided biopsy versus second look ultrasound? So in general, I'm a firm believer that you should guide your biopsy using the modality, which best sees the abnormality. So if you see this best on MRI, I personally prefer to do an MR guided biopsy because then I know I have biopsy the target that I was most concerned about. You can do second look ultrasound and I do do it sometimes for masses that are over a centimeter, or if I have a very complicated case and there are multiple biolateral findings, I have used second look ultrasound, but I have not found it to be very helpful for nonmass enhancement. I even had a case where there was a greater than four centimeter area of nonmass enhancement and the ultrasound looked entirely normal. My only caveat though is if you're going to use second look ultrasound for your biopsy of an MR finding, you might consider putting the patient back on the MR scanner to make sure that you have biopsy changes in the clip correct area. And the reason for that is the literature will show that about 25% of the time, you may not have actually biopsied a target that was seen on the MRI if you did the biopsy by ultrasound. And this is just an example. One of the cases I saw a couple of years ago where I had a very high risk patient. She had a focal area of nonmass enhancement in the farm medial inferior breast. Because of its location, we thought the MR biopsy would be very difficult. So we went to second look ultrasound, found a heterogeneous area, biopsy, it got patched, thought, okay, everything looks good. Everything's concordant. And then on her follow up a year and a half later, we noticed the clip was off. It was near the biopsy site, but it was about a centimeter medial or lateral to where the enhancement was. The residual enhancement didn't look significantly different, but eight months later, when she finally got a mammogram again, now in that area of enhancement on the MRI, we can see pleomorphic calcifications. And you can see that our biopsy clip was nowhere near that site. So what we had biopsy done to ultrasound, I'm not convinced was the correct target. We then, because again, because of the physician went back to ultrasound, but now could see the calcifications in an area of hypo coic, irregular tissue. And this was a low grade invasive ductal cancer with DCIS. So here to summarize, when you're looking at MRI, remember to use the MIP or the maximum intensity projection as an overview, as well as to get an assessment of the background, prankimal enhancement. Pay attention to your pre contrast T1 and T2 signal intensity for lesions that you're seeing on your images, because they can help you triage them into the more likely benign or need a biopsy category. You're going to assess your focal lesions for morphology and enhancement using the ByRADS lexicon. And then always remember to correlate your MR findings with clinical history, as well as imaging that you might have on the other modalities. Also to summarize, these are the features that are more likely benign. If you have a focus and there are multiple scattered foci, those are likely benign. If you have a solitary focus with below threshold kinetics, that is likely benign. Masses that are circumscribed round or oval or more likely benign, those with non enhancing internal separations are likely benign. T1 bright lesions or T2 bright lesions are generally benign. And lesions that have below threshold or even type 1 kinetics are more likely benign. For non mass enhancement, regional or multiple regions or diffuse non mass enhancement is typically benign. What are the features that are most likely malignant? Ones that are solitary foci that have suspicious kinetics. Masses that are irregular, have a predetermined, articulated T2 dark, show nodular or rim enhancement or have type 2 or 3 kinetics or more likely cancers. And for non mass enhancement, if you have focal linear or ductile or focal suspicious kinetics in an area that's more diffused or regional background enhancement or segmental enhancement or the clumped clustered ring pattern for enhancement, these are all features that would favor that something is more likely malignant and certainly would warrant a biopsy. So thank you very much for your attention. I'd be happy to try to take some questions. Yep, perfect. Before we move into the Q&A, I just want to thank everyone for participating in this noon conference and remind you that it will be made available on demand on MRI online.com in addition to all previous noon conferences. And please register for tomorrow will be joined by Dr. Jessica Robbins for a noon conference on imaging of malaria and duct anomalies. You can register for that also on MRI online.com. I'd like to ask a question to Dr. Sainett to be good. Please open the Q&A feature. I think there's some questions in there for you. Yes, I have. Okay. So. So let me just say, okay. So one of the people had asked, how do you distinguish fibratoid Noma from a phyloid, these tumor on MRI. So phyloid, these tumors, typically, you know, so the first thing I think is a very important question because when we do any kind of needle core sampling, the pathologists obviously to have very limited tissue to make the diagnosis and sometimes actually it's very difficult for them to confidently differentiate a fibratoid Noma from phyloids. So sometimes in their reports they'll hedge and then, you know, you have to go and do surgical excision. But typically there's nothing on MRI that I'm aware of that will distinguish those two. We don't necessarily, if I get a fibratoid Noma, and I think the lesion on the MRI is consistent with the fibratoid Noma, I actually just put them back into yearly MRI for their high risk screening, if they happen to be a high risk patient. Phyloids tumors might have some cystic areas within them because you do see micro cystic spaces in them. So you might on the MRI be able to on the T2 be more concerned, but atypical fibratoid Nomas could also have that appearance. The classic way to differentiate them, though, is more on clinical exam or on imaging, if they have rapid enlargement over a short period of time, and there you would end up doing a re-biopsy. So unfortunately I don't think there's anything on MRI that will definitively differentiate those two, and I don't think you necessarily need to follow at that point. Let's see. This is okay. Okay, so somebody asked the question, if the right breast has a biorets 2 and the left breast has a biorets 3, is it necessary to mention both findings and the impression? So first of all, when you're interpreting a breast MRI, most of us will just give one biorets code for the final assessment. There are a few facilities in the United States who give a biorets code for each breast. I personally find that for at least my referring providers, that gets very confusing. And I also worry if you use two biorets assessment codes, one of them might get picked up and the other one might get missed in the report by your provider. So I generally recommend using one assessment code. And for me in the impression, I generally only include the significant findings. So if something is absolutely benign, I put it in the body of my report, but if it didn't, was not related to the reason for why I ordered that MRI, I don't mention it in the impression. The impression really should just answer the clinical question or focus on the very significant or pertinent findings. Okay. Somebody brought up a question. What's your opinion about diffusion weighted imaging? So at my facility, I haven't had a lot of experience with diffusion weighted imaging. So I'm not sure I'm the best person to answer this, but I do think there are some people who really do find it helpful for differentiating something that's more likely benign versus malignant. The issue that I've had with diffusion weighted imaging at my facility is that we've had some difficulties figuring out what is the proper B value. So I do believe there's some ongoing research on this area. Eventually maybe it will be more widely adopted, but at least in the Boston area, many of us are actually not using it because we've found that it's not that the temp or the spatial resolution of the diffusion weighted images. So I think a small lesion really doesn't allow us to reliably differentiate benign from malignant. Let's see what else. Features of fat. Okay. So one of the questions on features of fat necrosis on MRI, and I think I covered that in one of the cases, but basically what you're looking for is if you have a lesion and there's signal within it that follows fat on multiple sequences, the T1, the T2 and the post contrast, that is the best way for differentiating process on MRI. It's obviously not a hundred percent reliable because fat necrosis can have a very variable appearance. The other thing is I would recommend if you're suspecting fat necrosis correlating with other imaging modalities can also be very helpful. Okay. There are lots of questions here, which is great. I've answered that. Okay. So there's a question about in the, for the kinetics, how many acquisitions do you recommend? I mean, in the first five minutes. So generally at my facility, we do a pre contrast and then we do four post contrast acquisitions within the first five to six minutes. There are some facilities that are only doing two post contrast. Again, in the United States, things are not standardized. There are also other facilities that are doing five or six post contrast. I think having at least three post contrast is usually useful because it gives you a better sense of the uptake in the initial image and then you get a better sense of the wash out over time. So you probably need at least five or six minutes post contrast imaging total so that you can get a good sense of the type of curve that you have. There's a question about what software tool you use or recommend for post processing the kinetics in the MIPS. You know, I don't have any affiliations with any companies where I currently work. We use a Dyna CAD, which I believe is a product of Hologic or in vivo. But there's also other, you know, I think all the companies that have products on the market that do the post processing are probably very comparable. What I would suggest if you don't have a system in place is to probably contact several of the providers of these different software packages and test them out because some of them probably have advantages for, you know, helping to guide your biopsies as well as for interpretation. And part of it's also what works best with your MR scanner and your PAC system because obviously the software needs to integrate with that as well. Okay. One of the people asked, when do you use a Byreds 3 for MRI for six month follow up? Do you also follow up for two years? When do you consider MR guided core biopsy versus six month follow up? So I think, you know, I didn't talk a lot about when do you use Byreds 3? And I think that's a very good question. I try to use it as little as possible. But if I really have a finding that I feel is probably benign and I don't feel that it needs a biopsy, then I will recommend that we follow it. And generally where I work, we're following it at the six month interval at the one year mark and at the two year mark. So we do a six month, the one year and a two year MRI. There are some places that I know of that just do that first six month follow up. And if it doesn't change at that point, then they have the patient come back in a year from that point. And I think that's probably a reasonable option as well, but I don't think anybody knows what is the optimal follow up protocol for MRI. But I would suspect that given how sensitive breast MRI is, you could probably get away with doing that first six month follow up and then see them back in a year after that. Okay. So there was a question about, I think I lost my mouse. Here we go. A question about how do you differentiate a small focal lesion from blood vessels? So, I mean, in this talk, I wasn't able to show you scrollable images, but as you're scrolling up and down in your sequences, it's pretty easy to see a blood vessel because you can actually follow his path and see it branching in the breast. So that's the best way to tell if something is a blood vessel. There was a question about if something's palpable, why wouldn't you just do the needle biopsy with the outdoing MR? Absolutely. If the lesion is palpable, I would just, you know, usually those are visible under ultrasound anyway. So you're going to be doing an ultrasound guided biopsy, or you can even just guide it by palpation. The MR biopsy really is reserved for things that we can only see well on the MRI and not well on other modalities. So, you know, I certainly would not do an MR biopsy on a palpable mass. It doesn't really make much sense. There was a question about linear enhancement can occur in periductal mastitis. Do you describe it as linear nonmass enhancement or do you describe it as mastitis and how do you differentiate? So I think, you know, periductal mastitis is challenging. I've seen a course in my career where I was able to more confidently avoid biopsy, particularly if you have a patient who has hyper prolactinemia. So they have an elevated prolactin and they've got a lot of periductal disease. But often it's very difficult to tell the difference between periductal mastitis or whether there could be a malignancy. So many times you're going to have to intervene and biopsy. But if I think clinically, based on the clinical presentation and what's going on with the patient on other modalities and there's nothing suspicious, you may be able to do some kind of follow-up imaging. If you're reluctant to do a biopsy in these cases. But I think most of the time it's very, very tough. Usually though, you'll see the T1 bright signal. You'll have other findings that will help lean you towards that more likely benign diagnosis. Perfect. I think we have time for one more question. If you see a good one in there. Yep, I'm looking, I'm looking. Okay. I think, I think this is a good question. What should be the next step of management? If the MR got a core biopsy is not available. So one of the things I forgot to mention, at least in the United States now. If you are doing breast MRI and you do not have the on-site capability to do a biopsy, if you are doing breast MRI and you do not have the on-site capability of MR got a core biopsy in order to be an accredited facility, you have to be affiliated with a site that can offer that service to patients. So I think it's important if you're setting this up, that you do have the capability, whether it's yourself or another practice in the, in the neighborhood or somewhere close by to you that can offer that capability. If you really don't have that capability, you're really going to end up relying on ultrasound to hopefully find the finding or met mammography potentially to identify a target for biopsy, but you're not going to be able to do, be successful 100% of the time. So it is important. Another option though, if you really are in a financially strapped situation or you don't have a practice near you that could offer that capability, you could try doing a CT guided biopsy. You can use the MR guided system under CT and you know, if there's really a suspicious finding on MRI, that lesion should enhance on the CT and therefore you could guide your biopsy under CT or you could even do a CT guided localization if you were able to see it. But in general, I would recommend that if you're going to be doing breast MRI, it's important to have that MR guided capability. So thank you very much. I'm sorry, I couldn't get to all of your questions and hopefully you found this helpful and hopefully it will help you improve your practices across the world. Thanks again. Perfect. Thank you so much Dr. Slenditz for your time today and thank you to all of you for participating in this new conference. Again, it will be made available on demand on MRI online.com in addition to all previous new conferences. Please follow us on social media at the MRI online for updates and reminders on upcoming new conferences. Thanks again and have a wonderful day.