Hereditary Breast and Ovarian Cancers Meeting 2011, New York, USA
Magnetic resonance imaging: advancements and benefits of use in screening
Professor Francesco Sardanelli – University of Milan, Italy
Francesco, Professor Sardanelli, you work as a professor at the University of Milan and at the Policlinico San Donato. You’re a big expert in magnetic resonance imaging and you were telling this conference that things have changed and things have really, really improved.
Yes, the main message we can give to breast cancer specialists all over the world is that the field of diagnosis and detection and diagnosis of breast cancer has dramatically changed in the last ten years. The main change was due to the development and the practical use of MRI among the radiological modalities. One of the most shared consensuses on the use of MRI is for the screening of high risk women. High risk women are not such a large number but this is a particular category of women with a quite different disease for frequency and for early onset if compared to the generic population. So these women who belong to particular families with a strong history of breast cancer and ovarian cancer should be treated and surveyed in another way in comparison with the general population. What we have seen and demonstrated also in the published papers is that the contribution to the diagnosis that the MRI in the screening is able to give is absolutely higher if compared to clinical breast examination, mammography and ultrasound. In terms of sensitivity for the presence of the disease, the contribution of MRI is so high that the residual possibility to detect a cancer when MRI is negative from mammography or ultrasound is practically negligible. So the message is that if we use MRI there is strong evidence that the negative result of the examination is highly reliable. This means that these women can go to normal MRI without having mammography, in particular before 35 years of age when the breast tissue is highly sensitive to ionising radiation given with mammography.
And of course the BRCA mutations give another potential risk of failure to repair from DNA damage from mammography.
Absolutely. This is particularly true before 35 but there is no advantage to give mammography as an adjunct to MRI if the MRI is negative.
MRI on its own; mammography and ultrasound do not add anything special.
No. This is confirmed not only by the target study but also by a German study published recently. So the two studies are quite comparable in terms of results.
It’s very impressive and it’s very helpful. Now you’re a leading light in the Italian group and you’ve also formulated the EUSOMA hit points...
Recombinations.
Just take me through them, just the main ones for clinicians watching this programme.
EUSOMA recommendations are not related only to the high risk. We considered ten debated indications and there is a general consensus on the use of MRI for the screening of high risk, for the detection of occult cancer when you have the metastasis and the mammography is negative, for the evaluation of the effect of the neoadjuvant chemotherapy where the cancer is large and you need chemotherapy before surgery and also in case of suspect of recurrence if you have a non-conclusive examination with conventional imaging and you do not have clearly a side to put the needle for the conclusive diagnosis. More discussed the indication in the appropriate group through which we defined the four indications, four shared indications, which is the diagnosis of lobular cancer, the high risk group, if you have a cancer in a high risk you need MRI as a tool for preparative staging, and also cases in which there is more than 1cm or 1cm discrepancy in the size of the tumour between mammography and ultrasound.
Now magnetic resonance imaging is, of course, not cheap. It costs money and it also can cost side effects and there can be more side effects when you give the contrast and sometimes contrast is contraindicated. You were mentioning the future, the possibility of doing without contrast maybe and maybe back to spectroscopy. What do you think the future holds?
There is some evidence in the literature, also in our experience using non-contrast techniques in MRI for breast cancer. The two main tools for this future are mass spectroscopy and diffusion weighted imaging in MRI. The main difference is that spectroscopy is quite difficult, it takes time to be acquired, it takes a physicist to be processed and analysed while DWI, diffusion weighted imaging, is fast, cheap and for sure easier to be interpreted.
And it’s already here, it’s with us.
So in these two, spectroscopy is very intriguing because we go to the metabolism of the cancer cell but diffusion is really important because we test the freedom of the water in the tissue and this is related to the level of cellularity: more cells, less freedom for moving the water. And the results are very important, in particular for the evaluation of the residual tumour after chemotherapy, already published recently in Radiology and also initially results are available for the detection. Because the restricted diffusion in the tumour makes a situation which we see a bright point in the diffusion weighted images and a low signal in the ADC map that is the post-processing. So for the future we can hope, we can work, about the ability of MRI to make the detection with these kinds of techniques and the characterisation with a contrast, but only a small fraction of the women who will have in the future the screening will need really the contrast. This is the scenario in which we are working now. This development of imaging techniques could happen if the whole community of breast cancer specialists work together about the results of the imaging because radiologists alone are not enough to get the results for our patients.
Multidisciplinary approach is…
Absolutely the word for the future.
Francesco, thank you very much, you’ve made it very clear to me. You’ve convinced me and I’m sure you’ve convinced our thousands of viewers to ecancer.tv. Thank you.
