USE OF MAGNETIC RESONANCE IMAGE IN BREAST LESIONS CATEGORIZED BIRADS IV - V - VI: NOTABLE CASE REPORTS FROM HOSPITAL EUGENIO ESPEJO

Glenn Mena O, PhD.*, Sara Varela MD.**, Paulina Avalos MD.**, Ma. Dolores Cisneros***, Marcia Zúñiga MD.

*Radiologist at Hospital Eugenio Espejo, Quito-Ecuador. **Postgraduates of Radiology at Universidad Central del Ecuador ***Radiology technician at Medicos Radiólogos.

ABSTRACT The BI-RADS® system aims to facilitate same language reading mammary image, improve the diagnosis, staging and intervention if that is the case. The picture by magnetic resonance (MRI) breast is a method of diagnostic complementation that provides and supports additional data like: bilateralism, multicentricity, multifocality, tissue scar, fibrosis post radiotherapy, axillary nodes, kinetic studies, spectroscopy etc., it must be made prior to the biopsy be- cause of the possibility of false positive results in scar tissue, detail that has been major point in our hospital. In Breast Clinic we have a clinical radiological control from the physical examination until the final biopsy respecting the imaging algorithm to avoid false positive or negative results in MRI. We present four practical examples where MRI has been proven to be of great diagnostic utility.

INTRODUCTION spectroscopy evaluate specific metabolites present in some diseases and it is useful when MRI shows Breast cancer (BC) is the main detected neoplasia indeterminate results. (4) among women in Ecuador and it is also a worldwide health issue. It accounts for 31% of The following section presents a series of cases of tumors of female population (1). The incidence breast conditions catalogued as BIRADS IV where reported in Quito is 35.8 % with an standardized MRI was useful to assess the final diagnosis. rate of 40.8. Data indicate this ratio has duplicated in the last 20 years, making BC the most frequent MATERIALS AND METHODS tumor of women in Quito. (6) The following reports include female patients age In 1992, the American College of Radiology 22 to 61 years old, diagnosed as BIRADS® IV, V or developed the BI-RADS®, which has been updated VI. The indications for an MRI comprehended: in 4 occasions (1993, 1996, 1998 and 2003) and it indeterminate results using conventional exams, is currently used for mammography, ultrasound and primary malignancy unknown, screening for a magnetic resonance imaging (MRI). (2) breast primary unknown (metastatic axillary adenopathies), evaluation of local extension of a BI-RADS® system aims to facilitate the breast cancer, suspicion of local recurrence after communication and language respect to the conservative treatment, follow-up under neo- interpretation of breast imaging, improving adjuvant treatment, lesional characterization MRI, diagnosis, staging and intervention if the case early detection of breast cancer, suspicion of requires it. (12) recovery tumoral regulation to the physical examination, mammography or ultrasound. Breast focused MRI its an alternative diagnostic and follow-up technique in breast disease. The MRI equipment used was a Philips, model Intravenous contrast has demonstrated high INTERA/Achieva 1.5 T, Software Release R2.6.3. sensitivity for breast cancer detection, especially The T1 acquisitions were made with TR 524/TE10; invasive types. The sensitivity of this method is T2 SPAIR plus TR 4000/TE70, thickness of 3mm, 0.90 (CI 95%: 0.88-0.92) and its specificity is 0.72 50 cuts and 6 dynamic acquisitions with 150 cuts (CI 95%: 0.67-0.77) although it varies among every 2 mm in T1 (gradient) TFE with fat tissue authors. suppression THRIVE (HEE).

MRI additionally reports: bilaterality, multicentricity, A breast support and 4 SENSE channel coils plus multifocality, axillary lymph nodes and it should be DRY STAR DT 2B 14x17in plates were used. With performed before biopsy due to the likelihood of a 4x5/2 matrix for T1 TSE and T2 SPAIR and 2x2 for false positive result in scar tissues. At the Breast dynamic curves giving a total of 4 to 5 plates per Clinic in our hospital, a clinical and radiologic study. The printer used was a AGFA DRY STAR control is performed, which starts with the physical 5300. The gadolinium intravenous contrast examination throughout biopsy following the (Magnevist 30cc) was administer using a existing algorithm in order to avoid false positive or MALLINCKRODT injector (0,3 cc/s). The negative results. (8,12) mammography studies were performed using an ALPHART GE, Stereotaxy and Lilyum Metaltronica. The more remarkable image findings include Ultrasound was performed using a GE Brand masses with irregular and spiculated contours, Echograph, Voluson 730 ProV model, with a high- irregular shaped and lineal micro calcifications, resolution, multi-frequency linear probe up to 13 ductal or arboriform. Furthermore, breast MHz. RESULTS showed a ductal infiltrating cancer on the left and a lobular infiltrating cancer with axillary Case 1 mets. on the right. Figure 6 shows a curve with double rapid emptying type 3. A 61 year old patient previously cataloged as a BI-RADS® 4b. The MRI showed various contrast uptake sources in the left breast (multifocality) and a type 3 dynamic curve. Histopatological results showed an invasive moderately differentiated lobular cancer. Fig. 1,2 and 3.

Fig. 1: Dynamic curve: THRIVE ROi4 with moderate ascent and fast clearing , type 3 in central source concordant with mamography

Fig. 4: BI-RADS 4C: mammography shows bilateral hyperdense sources, speculated and with tissue retraction. !

Fig. 2: Dynamic curve: THRIVE ROI3 with ascent and fast clearing , type 3, located in an addictional source non visualized on mammography.

Fig. 3: Dynamic curve: THRIVE ROI 1with plateau and slow-progressive clearing. Negative for a third source.

Case 2 Fig. 5: Breast ultrasound: hypoechogenic areas with acoustic shadow, verticalized and A 57 year old patient, previously cataloged as slightly vascularized. BI-RADS 4C. BI-RADS® 4c (Fig. 4 and 5). Breast MRI findings showed various bilateral uptake sources (multicentricity). Dynamic curves were type 3 on the left breast and type 2 and 3 on right breast (Figs. 7-9). Histopatological results Fig. 6: Dynamic curve type 3. Image shows adenopathy Fig. 7 Dynamic curve type 2. Image shows a speculated with high intensity and fast contrast uptake highly lesion, irregular, hypointense on T1 and hyper intense on T2 with fast contrast uptake with plateau. (Right) suggestive of right breast metastasis.

Fig. 8: Dynamic curve type 3 with double peak and fast Fig. 9: Dynamic curve type 3 with fast uptake plateau clearing. (Left) and prolonged clearing descending. (Left)

Case 3

A 26 years old patient, previously diagnosed as right breast cancer (BI-RADS® 6). Imaging studies were performed to assess post-surgical and post therapy control. Post-surgical fibrosis and irradiated tissue had ultrasound and mammography changes, difficult to classify. MRI showed hyper- intensity plus benign curves.

Fig. 10: Hyperechogenic diffuse areas on outer quadrant and prolongation with signs of scar-tissue fibrosis and Fig. 11. T1W TSE SENSE TR 524/ presence of methylene blue. Doppler US negative. BI- TE10. RADS 6 Hyperintense areas in the post- surgical sections. Fig, 12. AXIAL SPIR TSE SENSE TR Fig. 13. Dynamic curve THIRVE ROI 6 shows progressive ascent 524/TE10. Image shows hyper intensity and plateau formation, type 1A. areas in subcutaneous tissue and in post-surgical area.

Case 4

A 55 year old patient , previously cataloged as BI-RADS® 4a because of a vascularized nodule on the US image. (Figs 14, 15) MRI findings were benign (Fig 16, 17, 18). The results did not concord between imaging studies. Core biopsy was performed and histopathological findings showed a fibroadenoma with usual ductal hyperplasia.

Fig 14. BI-RADS 4a Mammography, hyper dense focal Fig. 15. US shows lobulated module, without shadow but area in upper outer quadrant. vascularized. High Pulsatile and Resistance indexes. BI-RADS 4b.

Fig. 16. MRI shows a hypo intense nodule on T1W TSE SENSE; AXIAL and hyper intense on T2W SPAIR TSE SENSE . FIG. 17. Dynamics, inverted scale with kinetic curve type 1, beningn.

kinetic changes as seen in Case 3. (13) A complete resolution seen in resonance does not mean a complete pathological response, so in these patients resection of the tumor bed remains essential in the treatment.

Magnetic resonance spectroscopy (MRS) provides biochemical information about tissues but metabolite quantification remains difficult in breast, nevertheless, it can improve MRI specificity and sensitivity which can diminish the need for biopsies in the future, what makes MRS a promising technique in clinical practice. Active metabolite measuring can be achieved using MRS with PADE calculation (PT: Fast Pade Transformer). (3) The results are promising for MRS in monitoring the Fig. 18. Sagittal T2 SPAIR. Hyperintense and regular response to chemotherapy. Also extras for lesion. Typically benign. shimming and suppression of water peak coadjutants in the new techniques (4)

Metacentric assays are increasingly necessary and DISCUSSION are a vital step in the establishment of this technique in the clinical setting and for control of MRI must be used in selected cases when recurrences, scar tissue and fibrosis (15, 16) as in alternative image techniques show indeterminate Case 3. findings. We chose four examples that represent common indications for MRI, which was useful to Breast MRI has a high sensitivity for cancer determine multifocality in Case 1, to confirm multi detection and a lower specificity which depends on centricity in Case 2, to ratify benign post-surgical observer experience, an appropriate technique and findings in Case 3 and to agree with correct patient selection as in our first two cases. histopathological findings despite a previously (16, 17) suspicious mammography and ultrasound in Case 4. CONCLUSION We did not include typical cases with unifocal carcinoma images which are well described in The use of MRI is fundamental to clear up doubts, medical literature and allowed the validation of ratify classifications, clarify multicentric or multifocal MRI. A systematic review and a meta-analysis of 19 commitments, plan therapeutic and perform post- studies about MRI assessment in multifocality and surgical and neo-adjuvant imaging control. MRI multicentricity not visible in conventional must be used rational, it has to follow not only examinations, showed that resonance detects more radiological criteria but it has to consider a cancer in 16% of patients. It varies its diagnostic multidisciplinary approach to achieve appropriate accuracy depending on the reference standard cost-benefit for the patient and institutions, and is used, decreasing from 99% to 86% as the quality of has to be ethic and effective. In our country, the the standard increases. (6,13) vast majority of RIM resources are available to When conventional methods show non conclusive design prospective research. Although some findings, the high sensitivity of the resonance for institutions may experience limitations in using the detection of cancer makes it useful in some MRS or specific software, it is not an excuse for not cases in which there are doubts with the physical studying or applying MRI and its benefits for breast examination or conventional tests. imaging diagnosis.

On the contrary, suspicious lesions may have a REFERENCES typically benign pattern in MRI, Case 3, with confirmatory histological benign. (10,11,14) Percutaneous biopsy still remains the best alternative, because the NPV of the resonance is 1. Eva Vilar Bonacasa Y Cristina Roig Salgado. not enough to replace it, especially in a negative Clasificación Bi-Rads Servicio De Radiodiagnóstico resonance with a mammography with Del Hospital General Obispo Polanco De Teruel. microcalcifications, in which the behavior based on 2. Belén Úbeda Hernández. Semiología. the mammographic findings should be taken. Clasificación Bi-Rads. Mamografía, Ecografía Y Rm. Institut Universitari Dexeus Breast MRI can be used before starting chemotherapy and once completed, to evaluate the 3. Maury Elena Rodríguez Ruiz,* Dora Luz response to treatment, ideally measuring tumor Barragán Patraca,* Nelson Fabián Villafañe volume, to predict early response to treatment is re- Marín,** Miguel Ángel Palacios Montesinos,*** mends add a breast scan after the first cycle of Luis Felipe Alva López***. Valoración Con chemotherapy , evaluating tumor volume and Resonancia Magnética Dinámica De Mama En Los Casos Birads 3 Y 4, Correlacionados Con 2006; Vol 39,N. o 2: 81-85 Histopatología 11. Camilo Fuster Palacio, Patología Benigna de 4. Lía Bartella, Md And Wei Huang, Phd. Proton La Mama. Clasificación Macroscópica. Polop de La (1h) Mr Spectroscopy Of The Breast Marina. Alicante, 2000 Radiographics 2007;27:S241-S252 12. American College Of Radiology (Acr). Breast 5. Paulina Neira, Dra. Patricia Arancibia, Dra. Imaging Reporting And Data System Atlas (Bi-Rads Bernardita Aguirre, Dra. Paulina González, Dra. Atlas). © American College Of Radiology; 2003 Teresa Taub. Revisión De La Literatura Sobre 13. Paul Peter Rose, Patologia Mamaria, Uso de Resonancia Magnética Mamaria En Cáncer Lippincott Williams, 2da Ediciòn, Editorial de Mama. Sociedad Chilena de Mastología Amolca, Philadelphia, Usa, 2007. Medwave. Año X, No. 1, Enero 2010. Derechos 14. Rostagno Román, Castro Barba Mariana. Reservados. Avances En Diagnóstico Por Imágenes. Colegio 6. Dr. Fernando Checa. Registro Nacional de Interamericano de Radiología. M. Stoppen .R Tumores Solca Quito 2003-2005 García Mónaco. Editores Cir. Ediciones Journal 7. Morris E,Libermann. Resonancia Magnética 2010. Pag 13 Dinámica de Mama, Editorial Marban New York 15. Horvath Eleonora. Pinochet Miguel. Avances U.S.A. 2010, 73,74- 207, 242 En Diagnóstico Por Imágenes. Colegio 8. Paul Peter Rose, Harold Oberman, Atlas de Interamericano de Radiología. M. Stoppen .R Tumores de Patología, American Registry Of García Móna Editores Cir. Ediciones Journal 2010. Patology, 1993 Argentina. Pag 71 9. Revista De Posgrado De La Via Cátedra De 16. Camps Herrero Julio. Pinochet Miguel. Medicina - N° 133 – Noviembre 2003 Pág. 12-15 Avances En Diagnóstico Por Imágenes. Colegio Displasia Mamaria – Revision Estela Virginia Mur, Interamericano de Radiología. M. Stoppen .R Julio Ernesto Cocco, Karina Liliana Tost Romero, García Mónaco. Editores Cir. Ediciones Journal Juan Rodrigo Alderete Dra. Adriana Benitez De 2010. Argentina. Pag 59. Mozzatti 10. Aranda López Fi, Peiró Cabrera G, Alenda González C, Lesiones de Células Columnares Y Atipia Epitelial Plana de La Mama Rev Esp Patol