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You can also sign up for a free trial of our premium membership to get access to

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hundreds of case-based microlearning courses across all key radiology

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subspecialties. Today we are honored to welcome Dr.

0:42

Em Emily Conant for a lecture on abbreviated breast m r i for supplemental

0:46

screening Early outcomes and tips for implementation. Dr.

0:51

Conant completed her radiology residency and fellowship in breast imaging at the

0:55

University of Pennsylvania,

0:56

where she currently practices her career has included extensive research in the

1:01

optimizing and delivery of high quality multimodality breast imaging to diverse

1:06

populations. In addition,

1:08

her current research includes the use of image processing and artificial

1:12

intelligence to improve screening performance and refined risk prediction For

1:16

more personalized screening.

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She has a longstanding commitment to excellence in patient communication,

1:22

clinical care, education and research. And we are thrilled.

1:25

She's here today to share her expertise. At the end of the lecture,

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please join Dr.

1:30

Kant in a q and a session where she'll address questions you may have on today's

1:34

topic.

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Please remember to use the q and a feature to submit your questions so we can

1:38

get to as many as we can before our time is up. With that,

1:41

we're ready to begin today's lecture. Dr. Conant, please take it from here.

1:46

Hi there. Hi everybody.

1:47

Thank you all so much and it's really an honor to be here. Um,

1:51

got a lot to talk about and I look forward to all your questions. Um,

1:54

let me see if I can get this going. There we go. Okay,

1:57

so we're gonna talk abbreviated breast, Mr. Today,

2:00

the how and why of clinical implementation. Here are a couple of, um,

2:03

disclosures, research, support, et cetera. We're gonna review breast, uh,

2:08

MR screening and high intermediate and average risk women initially just to get

2:13

some background information and then look at the evidence supporting why we

2:17

wanna go with this abbreviated format of the breast, mr,

2:19

and how we can expand our use of, uh, MR in larger populations.

2:23

And then give you some early clinical outcomes. So background,

2:28

abbreviated protocols are really where it's at. Can we cut these down?

2:33

Can we make them equally accurate but more efficient?

2:36

And it really is about money, keeping the accuracy,

2:40

but making a faster,

2:42

more efficient study so that we can decrease the cost and hopefully allow more

2:45

access to more patients that need these study of all sorts, not just breast.

2:50

So we know mammography is basically the, the, the basis of screening.

2:55

And we know that we can decrease breast cancer mortality by routine screening

3:00

with mammography. However, it is far from perfect, as you know.

3:03

It's got fairly low specificity, lots of false positives. You know,

3:07

in mammography you see a mass, you don't know if it's a cyst or what.

3:11

So they're recalled. And then sometimes, even many times, um,

3:14

most biopsies are benign. So low specificity and then low sensitivity.

3:19

And we know that is particularly impacted by increasing breast density.

3:24

So here four women of the four birads categories of breast density all the

3:29

way on the left. A is the fatty, then B is the scattered,

3:32

C is the heterogeneous, and D is the crazy, extremely dense.

3:36

And all of these women have breast cancers.

3:40

And this increasing density,

3:42

we know is also an independent risk factor beyond just family history and things

3:46

like that. The more dense glandular tissue you have,

3:49

the larger the garden for cancers to grow. So increasing density,

3:52

increasing risk of breast cancer, and also decreasing mammographic performance.

3:57

We can't see them. So here are the cancers in these women. Oh,

4:01

50% of women have dense breasts in the United States. So here are the cancers.

4:05

There's a tiny one in the fat fatty breast, a you can barely see it,

4:09

but it was detected. There's a larger one in the scattered.

4:13

There's actually calcifications in the category C woman that were

4:18

detected mammographically and the woman category D, extremely dense.

4:22

You can't see anything even in a tomosynthesis image.

4:25

And this is it on ultrasound.

4:27

It was detected by abbreviated m r I'll show you those images later.

4:30

So you can see the size. Um, seven millimeters, two centimeters,

4:34

three centimeters, 3.5 centimeters. Um, again,

4:37

increasing risk of cancer development and increase decreasing performance.

4:42

So I'm gonna go through some of the background history here about mr.

4:46

And the biggest trial really that I think, um,

4:49

well the most important one early on was the AVA trial.

4:52

This was Christiana Cool, who's very famous for all sorts of breast, Mr. Um,

4:57

and this was, um, about almost 700 asymptomatic women.

5:01

And these were high risk women, greater than 20% lifetime risk,

5:04

who underwent annual screens. They had clinical breast exam, mammo ultrasound,

5:09

and this was full protocol, Mr not abbreviated yet.

5:12

These were read independently to those studies and in different combinations

5:16

together. And this was a really beautiful study and looked at, um, you know,

5:20

follow up as well for, uh, outcome.

5:22

So mammography found cancer detection yield of 5.4 per

5:27

thousand. This is again, a high risk population. Ultrasound, six,

5:31

mammo plus ultrasound, cuz it's complimentary. 7.7 mri,

5:36

almost 15 MRI plus ultrasound.

5:39

Catch that no more by adding ultrasound to r i.

5:43

That's a very important note. Mammography, however,

5:47

adds to M R I because you can imagine very small early DCI

5:52

SS that are only small areas of calcifications.

5:55

We may not see those as enhancing lesions on r i.

5:58

Adding ultrasound again to MR and mammo, no additional cal, uh,

6:03

cancers detected. So MR.

6:05

Combined with mammo finds the most cancers. That's the way to go. So, um,

6:11

let me, I I have something blocking. There we go.

6:14

I hope you all can see there was something blocking my screen. Anyway. Okay,

6:17

so conclusion for screening. High-risk women, again, high-risk women. Um,

6:21

these are the outcomes there.

6:22

And you can see clearly that Mr Plus mammography has the, uh, the highest,

6:27

uh, performance.

6:33

Then came the Akron 6 6 66 trial.

6:36

This was screening ultrasound Wendy Berg's trial. Very important, um,

6:39

adding ultrasound, uh, screening to women with, uh,

6:43

non-actionable mammograms. And these were mostly women with, um, high risk.

6:49

Um, at least, um,

6:50

half of them had prior breast cancers and the other half were considered high

6:54

risk based on familial history and things like that. Um, interesting.

6:58

At the very end of this,

6:59

after three rounds of non-actionable screens with the ultrasound and mammo,

7:04

MR was added at the very end. So let's look at these results.

7:08

Here's the mammo alone, round one versus round two.

7:12

And these are sequential rounds. Ultrasound only.

7:15

You can see the cancer detection.

7:17

Mammo plus ultrasound better because they're complimentary.

7:20

Supplemental ultrasound yielded 5.3 per thousand cancers. Um,

7:25

cancer detection into the first year additional in the second year,

7:30

a seven to eight absolute increase in recall. Again,

7:33

specificity is an issue with ultrasound.

7:35

And after three rounds of combined screening,

7:38

20% of the patients had short-term follow-ups. Women hate short-term follow-ups,

7:43

category threes, they hate them. So let's see about the r i.

7:47

So here's the mammo alone cancer detection rate at 8.2. This is overall,

7:51

and this is mammo plus ultrasound. It goes up a little bit.

7:55

Add the MR 26.1 for a difference of additional almost 15 per

8:00

thousand screen cancer detection. Mammo plus mr. Again, very,

8:04

very good versus mammo alone, uh, MR alone.

8:08

So combining r i and mammograms are the way to go

8:14

After three rounds of negative mammo ultrasound, MR detected,

8:17

14.7 per thousand additional cancers, that's about 1.5%. Again,

8:22

these are high risk for women with prior breast cancer history,

8:25

a four times greater cancer yield than adding just ultrasound to mammograms.

8:30

So ultrasound screening as a supplement is very, very common.

8:34

And it does find cancers, but it's not nearly as impactful as M R i.

8:38

So no doubt Mr. With mammography is the way to go. Here's just an example.

8:42

This is a woman who's extremely dense. Um, she had a negative mammogram.

8:47

She even had, um, an ultrasound,

8:49

and you can see the duration is October of 2012. And then, um,

8:54

March of 2013, here's her m r i of the right, here's her m r of a left.

8:59

So diffuse enhancement. This is not something that might be detected on, um,

9:04

ultrasound because it's larger than the field of view,

9:07

even whole breast ultrasound, but diffuse, diffuse enhancement.

9:11

And this was an extensive invasive ductal carcinoma.

9:16

So what about cancer biology always important. Are we just finding slow growing,

9:21

you know, low stage. This was an important study by Janice Sung etal,

9:25

including Chris Comstock, a retrospective review of high risk women.

9:28

What kind of cancers were found by these different modalities?

9:32

Most of them were detected by MR in this group. Um,

9:36

a smaller amount by mammography. And there were actually 12 invasive, uh, I,

9:40

I'm sorry, interval cancers as well.

9:42

And I love this graph because what you can see along the bottom is increasing

9:47

tumor histology grade. So worse, more aggressive D C I S,

9:52

low grade is all the way there on the left at the bottom.

9:54

Then it gets intermediate grade D C I S, high grade D C I S.

9:58

Then we get microinvasive invasive ductal carcinoma with a low grade,

10:02

intermediate grade, and high grade. And look at these different curves.

10:06

The MR screening has, uh, that's the mammogram line, sorry,

10:11

has decreasing, um,

10:13

aggressive biology finds more D C I S,

10:17

less high grade ones because those high grade ones sometimes are round balls,

10:21

like triple negative cancers. But look at the M R i increasing tumor histology.

10:26

And those are the ones we really, really wanna find. I mean,

10:28

we wanna find them all in my mind.

10:30

But those aggressive tumors are the ones between screen that can cause problems.

10:36

So more cancers with r i and more often invasive and higher grade than those at

10:40

mammography. Um,

10:42

now we move on to women with average risk that get supplemental MR screening,

10:46

this was another Christiana Kool very important study. Um, and she had, um,

10:51

over 2000 women who had multiple sequential screens.

10:55

And these were full protocol, mr. She found 60 additional cancers,

10:59

good combination of D C I S and invasive cancers.

11:02

There were 48 at that first round. 13 at the, uh, second round.

11:06

There was one cancer actually found by all, um,

11:09

three modalities in retrospect,

11:11

but no cancer diagnosed only by the mammography or only by ultrasound and not by

11:16

MR. Zero interval cancer rate. And, uh,

11:19

cancer detection rate by MR 15.5 per thousand.

11:23

Good rate. And it wasn't about density. This was women of all densities.

11:28

So here's the numbers. You can see the different density categories, a, B, C,

11:32

and D. And you see the percent of women across the whole, all the women who had,

11:37

um, cancer diagnosed. And so it shows you that even in those,

11:42

um, low density breasts, cancers were detected by MR only.

11:48

And these Mr uh, the MR detected cancers tended to be small node negative.

11:53

Yet high grade. So aggressive cancers, those are the ones we really wanna find,

11:57

find them early. So why not more breast? M r i, these are kind of old numbers,

12:02

but it's really about dollars. Um, uh,

12:06

an MR costs a lot. Um, look at the private billing co, um,

12:10

number thir $3,000 versus a mammogram or a breast ultrasound.

12:14

So how can we make this less expensive? Also, according to Berg Atal,

12:19

they're not always well tolerated. You know, there's claustrophobia,

12:22

there's also contrast given that's a, you know, some for some that's not, um,

12:26

a good idea. Um, and in terms of full protocol,

12:31

Mr. The same protocols used for diagnostic and screening.

12:34

Some people worry about gadolinium deposition.

12:36

We're not as concerned about that. Um, I think now,

12:40

but how can we make this more efficient, more cost effective as well.

12:43

So what about fast or abbreviated mr.

12:46

So this is all about early enhancement, abbreviated mr.

12:52

And that early enhancement ratio is a measure of the contrast wash in,

12:56

and it le it correlates nicely with lesion conspicuity earlier, wa earlier,

13:02

um, enhancement, higher conspicuity.

13:04

And it also interestingly relates to tumor grade,

13:08

a proliferative index of K 67 and aggressive tumor grades.

13:13

And so leveraging that early enhancement is the concept behind abbreviated mr.

13:18

Early enhancement is seen in bad prognostic cancers and less often in false

13:23

positives or low grade lesions.

13:25

Remember that may be imaging late delayed scans as in

13:30

full protocols. Maybe that increases false positives and lower specificity.

13:36

So here we go. Here's a full protocol, um, MR and you know, it has a t2,

13:41

a pre contrast t1. We do diffusion at our site on all patients.

13:45

Then we do three post contrast and sometimes even a fourth one.

13:49

And then there's the reconstruction, which isn't a table time, uh, activity,

13:53

but you know, we have to consider it. Um,

13:55

what sequences are absolutely essential? Well,

13:58

you need the T1 and you need the post contrast, the pre and the post.

14:03

Mm, maybe you need the t2. We'll talk about that a little bit later on.

14:07

And so abbreviated protocol that we use right now is a t2, a pre contrast t1,

14:12

and then one post contrast, and then the reconstruction of course is done.

14:18

So abbreviated proto protocol, again, Christiana Cole,

14:21

great stuff did a prospective trial.

14:23

These were high risk women with a negative mammogram. Remember,

14:26

high risk women who had had, um, had some annual uh, screens,

14:31

they had a full scan as well as the abbreviated protocol read.

14:35

This is what her abbreviated protocol notice.

14:37

There is no T2 in this pre contrast post contrast,

14:41

a subtraction created post, you know, um, you can do that later.

14:44

And then a MIP fusing all of the subs results.

14:48

She looked at table times,

14:50

both table time and read time decreased between the fast versus the full.

14:54

She did her fast in three minutes. That is super fast. But remember,

14:59

she didn't have a t2 and that's the longest of the sequences to do versus

15:03

21, which is very fast for a full. And the read time, she even compared,

15:08

I don't know, that's pretty fast. 2.8 seconds for looking at the mip.

15:12

28 seconds for the subs.

15:14

All 11 cancers were detected by both studies.

15:18

10 on the MIP of the fast, just looking at the MIP in 2.8 seconds.

15:22

I don't know if I could do that really, but anyway. And 11, um,

15:25

when the whole fast was looked at. So sensitivity, very,

15:28

very good additional cancer detected. And this is high risk,

15:32

18.2 per thousand cancer detection rate. Look at this.

15:37

I alluded to this.

15:38

Early specificity was similar with the abbreviated MR versus the full MR

15:42

actually in her small study, the specificity was a little bit better.

15:46

Look at that. 94.3 versus 93.9, not statistically significant,

15:51

but you know,

15:52

when you're looking at breast mr sometimes those things that are very late

15:56

delayed and enhancing, they may, may be the false positives.

15:59

They're certainly the lower grade cancers. I still believe in finding those.

16:03

But interesting about the specificity.

16:06

P P V pretty good and similar full versus, uh, abbreviated protocol.

16:11

So then we roll into the very famous Akron 1, 1 41,

16:14

comparing a true abbreviated mr um, to tomosynthesis.

16:19

Now not just two de mammography and average risk women with dense

16:24

breasts. That means heterogeneous or extremely dense breasts. There were 14, um,

16:28

when this was published, and this was 2020.

16:30

There are now new data coming out on sequential rounds in this Akron 1, 1 41.

16:36

Um, but in this first publication there were, uh,

16:39

about 1400 women. They got both, uh,

16:43

tomo and the abbreviated m mr in a randomized orders.

16:46

And the studies were interpreted by two different radiologists independently.

16:51

Um, and then they were, um,

16:52

screened twice one year apart and followed for three years for outcomes.

16:56

And in their analysis by RADS three, four,

16:58

and five were considered positive results.

17:01

So what we have here is the first year in that publication,

17:04

there were 23 women diagnosed with cancer.

17:07

17 invasive six dcis.

17:10

The abbreviated MR found almost all of them.

17:13

There was one that was found by the tomo, it was an er,

17:16

negative high grade DCI s DYS calcs. So again,

17:20

important to have both the mammogram and the abbreviated MR of the 14 seen only

17:25

by M R I. Um, again, that one was not seen.

17:28

So here you can look a little bit at the, uh, histology. This is the cancer. Um,

17:34

comparing the two, and you can see D B T had, um,

17:39

14 negative tests where cancer was found by the abbreviated MR.

17:45

Nine positive tests by the D B T. And again, on the abbreviated mr,

17:50

you had that one cancer, that was the D C I S found by, um, mammography D B T,

17:55

but not on the M R I. So sensitivity,

18:00

we compare, look at that,

18:02

almost 96% sensitivity with the abbreviated mr.

18:06

And these are women with dense breasts. So you know,

18:08

the sensitivity is not great. 39% only specificity, again,

18:13

not as good with abbreviated tomorrow because you're gonna see other things

18:16

because of the contrast and the enhancement.

18:18

P p v of biopsy still acceptable with the abbreviated mr additional imaging.

18:23

Like, come on back, I need to see,

18:25

I need to do mag views or whatever with the tomosynthesis ultrasound needed. Um,

18:30

and there were cases in the abbreviated m r where additional imaging was

18:34

recommended to see if lesions were seen and ultrasounds performed as well.

18:38

So characteristics of the cancers very, very important.

18:41

This is looking now at the mass, uh, the,

18:44

the max histology of the invasives and look here,

18:49

abbreviated mr. Look at that. There were low grade,

18:52

intermediate grade and high grade. Um,

18:54

and then the combination you can see on the far right.

18:58

And then you see the max histology for D C I A S. Again,

19:02

more commonly,

19:04

more aggressive lesions with the abbreviated MR protocol than the D B T.

19:10

Here's some, uh, data now from my institution. Um,

19:14

we started doing abbreviated MR with the, um, full support of our chairman,

19:19

Dr. Shaw, who, you know, as a leader in, uh,

19:22

r I and so many other things. Um,

19:25

we were able to convince him or he was involved in this decision that we were

19:29

gonna start an abbreviated protocol for women with dense breasts and

19:34

non-actionable mammograms.

19:35

And we started this back in 2016 and I'll share you some of our results.

19:39

We chose not to be in the Akron study because we are doing this at our, um,

19:43

our site. Instead. Again,

19:45

average risk women who did not qualify for full protocol, MR.

19:49

Dense breast had a non-actionable screen in the prior year.

19:54

And we do a t2, which is about four minutes,

19:57

a pre GAD and a post gad each one about 2.3 minutes.

20:01

So for a total of about 8.6 minutes,

20:04

we do our post GAD around 20 to 30 seconds after injection.

20:08

So a total of 8.6 minutes about, and then the reconstruction is done.

20:12

We'll talk about that should be done not while the patient's on the table.

20:16

So in this publication we had 511 women. Um,

20:20

some of them got excluded because of some different issues. They weren't dense,

20:24

um, they hadn't had a tomo. Um,

20:27

there was some GAD extravasation and they didn't wanna come back, et cetera.

20:31

But here were our outcomes. We did have, um,

20:33

13 patients who were put in category three,

20:35

and that's category three for follow-up, mr. Um,

20:38

and then 42 patients that were category four or five,

20:42

some opted not to have biopsies performed, believe it or not,

20:46

some had biopsies canceled.

20:48

I don't have the data on who refused and what happened to her. Um,

20:52

but we had 12 cancers and 11 women.

20:54

And I'm gonna show you some of these examples in a moment.

20:57

Of the 38 patients with 39 biopsies, um,

21:00

the majority of course had benign results,

21:03

but there were 12 patients with 13 cancers. A pretty good predictive, uh,

21:07

value at, um,

21:08

around 31% of those recommended for biopsy seven invasive five high

21:13

grade DCI S is good PPV two and good PPV three,

21:16

the 13 patients assigned the birads category three.

21:19

There was actually one cancer in that group.

21:23

Eight months after the category three recommendation.

21:26

We did a biopsy and it was a, uh, small cancer.

21:29

So overall our cancer detection rate,

21:31

remember average risk women just dense breast 27.4

21:36

after negative D B T or not actionable study that's incredibly high.

21:41

It's higher than Christiana Cools and others. Um, very,

21:45

very high couple examples. So here's one, you can see the, uh,

21:49

the MIP up top and then the axial, uh, uh, re um, uh,

21:53

subtraction on the bottom on the left. And then we've got the, um,

21:57

sagittal reconstruction.

21:58

You can see this irregular mass and there posterior somewhat lateral breast

22:03

right there, there. And this was an invasive ductal carcinoma. E R P R positive,

22:08

HER two negative. Here's one again, fairly dense.

22:11

Look at the way that little round ball is not distorting.

22:14

It's buried in the band of glandular tissue. And that was, uh,

22:17

invasive ductal carcinoma.

22:21

That woman we actually brought back, we did extra views.

22:25

Maybe there's actually distortion now on the tomosynthesis, I think there is.

22:30

And the targeted ultrasound showed the lesion.

22:32

Look at it in that band of dense breast tissue. And again, that was, whoops,

22:36

that was an invasive ductal carcinoma.

22:38

And so we did bring her back for additional imaging. Um,

22:42

here's a woman who had a, um,

22:45

lesion on both sides.

22:48

We actually recommended biopsy of the left area of linear

22:53

enhancement and said if the left was positive,

22:56

then she should have the right biopsied.

22:58

So we kind of hedged a little bit on this one,

23:01

but they were both high grade D C I S. Those are myth images there.

23:07

Um, so I just wanted to share with you a very recent publication. Um,

23:11

this is a meta-analysis of, um,

23:15

of supplemental breast cancer screening and women with dense breasts and a

23:18

negative mammogram. And this is supplemental in this case is defined. This is a,

23:23

uh,

23:23

non-American study as supplemental with tomosynthesis in addition to two de

23:28

mammography ultrasound and M R I. They looked at 22 studies and um,

23:33

about 261, uh, thousand screens. I know this is very,

23:38

very busy, but if you'd like references, um, here you go.

23:41

And I just wanna circle here the MR results. You can see the incremental,

23:46

um, cancer detection, 25.7,

23:50

very large invasive cancers, additional almost 20 per thousand.

23:55

Um, uh, there were some interval cancers, as you can see there.

23:59

Increase in incremental D C I S,

24:01

pretty good PV one and p PV three as well. Mr.

24:05

Superior and incremental cancer detection,

24:07

both insights to an invasive and really no statistical significance across the

24:12

modalities in P PV one and three.

24:14

So pretty impressive results again in this very, very large meta-analysis.

24:20

Oh, incremental D C I S per thousand screens. I mean, very interesting.

24:24

There you go. What about sequential screens?

24:28

What about how often should you have them? Should you have them every two years?

24:33

What happens after you've had one? So we wanna look into this a little bit.

24:37

This is one, uh, who came the, uh, study that came from Korea.

24:40

And this was almost 2000 women going, undergoing about 3000 um,

24:45

exams. And they were a mix of mostly high or intermediate risk.

24:50

There were some average risk women with dense breasts, but a very small number.

24:54

So remember higher risk women looking at the typical outcomes.

24:58

And this is interesting because their results are important,

25:02

but very different than what we found in average risk women.

25:05

And I'll show you that they found 38 cancers,

25:09

29 of those detected by abbreviated mr.

25:12

But nine false negatives of the nine false negatives,

25:16

they were all node negative.

25:17

And seven of those nine were not seen by the abbreviated mr,

25:21

but were seen by another modality. And two were true interval cancers.

25:26

So if you look at their cancer detection rates here and their sensitivity and

25:31

specificity,

25:32

their cancer detection rates per thousand screens of the MRS are much

25:37

less than what we've been seeing, which is interesting. Um,

25:41

10.7 in year three, seven or so per thousand in year one,

25:46

8.6 in year two.

25:48

And the sensitivity is not as great as what we have been seeing in some of our

25:52

studies. But the specificity is higher because they're biopsying less,

25:56

but also sensitivity is less. So very, very interesting.

26:01

Somewhat different results than what we've had. Biopsy rate,

26:03

very low short-term follow-up rate. We hate those category threes also low,

26:08

but I just wanted you to see this.

26:10

Now I want you to see now data that we presented my colleagues and I

26:15

at R S N A last year on our sequential rounds.

26:19

Now we had a total of, um,

26:22

about two 1800 women who had more than one study

26:27

and we looked at the baseline results of their abbreviated m r versus their

26:31

subsequent uh, rounds. And you can see the cancers,

26:35

you can see the cancer detection rates.

26:38

And we maintained a pretty high cancer detection rate on the subsequent round

26:43

16.8 in subsequent versus 17.6. And that,

26:48

remember this is looking at the women who've had more than one mr.

26:52

So not our whole volume of women that I present to you earlier that had a 24.7

26:58

per thousand cancer detection rate. But this is pretty good.

27:02

So how, how frequent were these between baseline and subsequent?

27:07

The mean, um,

27:08

interval between the consecutive studies was actually a little over a year.

27:13

It was 755 days. So they weren't getting them in general every year,

27:17

but a little bit longer than that.

27:18

And I think this is something that we need to look at. You know, perhaps, uh,

27:22

the supplemental screening with MR should be yearly for premenopausal,

27:27

maybe as women age. It may become every other year, of course. Um,

27:32

it's something that we need to consider,

27:33

but there was no significant difference in the cancer detection rate on our

27:37

baseline versus subsequent studies. Fascinating. There was a trend,

27:41

as you can imagine, of higher PPV two and three.

27:45

That's the positive predictive value. So calling something, um,

27:50

um, actionable, um,

27:51

it makes sense if you've got a prior to compare your PPV two and three should

27:56

become better because you've got like a baseline to compare to.

27:59

I hope that makes sense. Sense.

28:02

Birads 3% again got better because you had something to compare to.

28:08

Um, very,

28:09

very interesting compared to the data presented in that prior Korean paper.

28:14

But this cancer detection rate was maintained.

28:17

And here's the type of cancers, the majority of the cancers were early stage,

28:22

stage zero or stage one. And you can see that also on the subsequent rounds.

28:27

You're not seeing any high grade one, stage two, three and four.

28:30

There was one stage three at baseline imaging in this small less

28:35

than 2000 group that we had at our site. We're looking at, uh, writing this up,

28:40

um, anyti sometime soon. So here's an example. This woman actually had three,

28:45

she had a February, 2017,

28:47

then January, 2019 and then February, 2021,

28:50

she's kinda like on the every two year plan. Um,

28:53

52 year old with extremely dense breasts. Look how dense they are on the mr.

28:57

You can see. Um, and the third round abbreviated mr.

29:01

You see the small enhancing mass, six millimeters in the left breast.

29:06

Now could you see it before? It's certainly doesn't look actionable to me.

29:10

So this was um, I think a very good catch. Again,

29:13

we went back to her mammogram, could not find it on, on um,

29:17

a tomosynthesis study but did a targeted ultrasound in this case.

29:21

And there it is. You can see it on the far right, a small round mass,

29:24

very posterior when she's lying supine obviously.

29:27

And this was an invasive ductal carcinoma, erpr positive.

29:33

Here's another one. This is a 70 year old with extremely dense breasts.

29:38

Negative mammo screening.

29:39

Ultrasound actually had been been performed five months prior. Look at the mass.

29:45

Interesting, huh? The second round abbreviated mr.

29:48

This was October, 2018. And then November 22, uh, 2020,

29:53

sorry. So about two years and nothing on the prior you really don't see a thing.

29:57

And again, remember she had that screening ultrasound five months prior to the

30:01

November, 2020, MR five millimeter mass, birads five,

30:06

here you go. Targeted ultrasound, not seen clearly on the tomosynthesis,

30:10

but targeted ultrasound probably would've been seen with screening ultrasound at

30:13

this time, but not five months prior. Curious,

30:15

this was an invasive duct carcinoma, again, an E R P R positive.

30:20

So subsequent abbreviated MRS had a lower ABN abnormal interpretation

30:25

rate and higher PPV one PPEs, um, compared to baseline.

30:29

That makes sense cuz you've got something to compare to.

30:31

Cancer detection was maintained on subsequent rounds of abbreviated MR compared

30:36

to the baseline. That's very remarkable.

30:39

And all cancers detected on the subsequent exams were still early stage,

30:43

which is great. So really important if you're thinking about this,

30:47

I'm gonna give you some tips now for implementation is how fast is

30:52

fast when you're really doing it. How fast,

30:56

how efficient are you? So here expected, um,

30:59

times full protocol is around 26 minutes. Abbreviated is about 8.6. This is,

31:04

you know, what we do at at Penn, um, including diffusion, which is a long study.

31:09

Um, and you can see as I alluded to earlier, the T2 stir is the long one.

31:13

It takes about four minutes the way we do it now,

31:15

there are ways to shorten that. Um, but this is what we do right now. Um,

31:20

so total scan time and when we measure this and we publish this, um, actually,

31:25

um, I should, I don't think I have the right reference down there, but in um,

31:30

in, uh, we have published this in the journal of, um, academic radiology anyway,

31:35

um, total scan time,

31:36

expected scan time was the sum of the acquisition times from each series.

31:40

The actual scanning part,

31:42

the actual scan time was what did it really happen based on the DICOM time,

31:46

you know, when you pull up the images,

31:48

when did it really start and when did it really finish?

31:50

We wanted to see how efficient we were.

31:52

Total scan times again opening to closing the exam in risk.

31:55

That's the technologist and the technology activity times,

31:58

there's the total scan time,

32:00

minus the actual scan times and then we divided it into scan related activities

32:04

and nons scan.

32:05

So we're really trying to be efficient so we can get the full bang for the

32:09

time and the investment. So process map, sorry it's a little geeky,

32:15

but basically the patient arrives an M R I, these are external things.

32:19

The tech opens it in wrists, escorts the patient to the room,

32:22

she has to position the patient, starts the scan, plans the slices,

32:27

runs the scan processes, images in scan, offloads the patient, patient leaves,

32:32

tech closes, study on wrist. And so we have these external,

32:37

um, and other um, times that we have to look at.

32:40

They're nons scan related activities, which are the blue boxes.

32:43

The scan related activities are actually when she's dealing the technologist is

32:47

helping the patient. And then the actual scanning time is the yellows.

32:51

That's the real active time where you're imaging. So let's look what happened.

32:57

We looked at the abbreviated protocol and we did this early.

33:00

We only had 70 versus full protocol. And if you look at our sequences,

33:05

the abbreviated MR should be 8.6 minutes, right?

33:08

And the full should be around 26. When we looked at the DICOM headers,

33:12

what were the time? Whoa,

33:14

17.5 minutes versus 28.

33:17

That's not much of a difference in the full protocol,

33:19

but what's going on in the abbreviated protocol?

33:23

Total scan time and opening, closing the risks,

33:26

they're getting pretty similar tech activity time.

33:29

Very similar even though they're less sequences,

33:32

significantly fewer sequences on the abbreviated protocol scan related

33:36

activities. Very high for the abbreviated protocol.

33:40

Non scan related activities as well. What's going on?

33:44

Why are our fast protocols not so fast? We weren't real happy here.

33:49

So what did we do? We went back and we engaged our technologists,

33:53

not reprimanding, but engaging them in.

33:57

What were they doing when the patient was actually on the table?

34:01

Were they doing their reconstructions while the patient was on the table?

34:06

They should do that afterwards.

34:07

How can we make this a more efficient fast study study?

34:11

And there were lots of variability. The tech times varied. Um,

34:15

the non scan related activity varied.

34:17

The table time varied greatly between technologists.

34:21

And so having this kind of operational feedback was very,

34:25

very important. And we shared this as a team in a positive way,

34:29

how to make this more efficient and maintain our accuracy,

34:33

optimize our schedule, et cetera. Um,

34:36

T2 again is the longest sequence. Is it really necessary?

34:40

It takes about four minutes.

34:42

Well we did a retrospective review of that looking at the, um,

34:46

with sequential reads without T2 and then with T2 to see how it impacted

34:52

our interpretation of these studies. Abbreviated ones, again,

34:55

T2 takes about four minutes versus the, um,

34:58

the pre GAD and the post GAD make a whole study of 8.6 and then that

35:03

reconstruction get her off the table.

35:07

T2 Stir impacted the clinical decision making only in about five of the

35:11

196 patients. So 2.5% and I'm gonna show you examples. Again,

35:16

this was a small series of about 200 women. And here you can see,

35:20

let me see, I highlighted two cases.

35:23

You can see the birads category without the T2 were actionable.

35:27

They were recommending biopsy category four, but when the T2 was made available,

35:33

that lesion was downgraded to benign. I'll show you examples.

35:36

Things like fibroadenomas, which have a very typical appearance on mr,

35:41

but you need that t2 and three cases.

35:45

Whoops. Yeah, were downgraded from category three to benign.

35:51

So T2 did help. The question is,

35:54

does it need to be every year if she had a se uh,

35:57

sequential studies and she had a T2 last year, does she need one this year?

36:00

I can tell you we still include our T2 in our abbreviated protocol.

36:04

Here's an example. I hope you can see there's a small enhancing, uh,

36:08

lesion over on the right side. There's a little blown up image.

36:14

Her t2, it's obviously T2 bright.

36:17

And so this was downgraded to benign looks like, you know,

36:21

sort of a fibroadenoma and it continued. It was fine on follow-up as well.

36:25

Here is another, um,

36:26

enhancing sort of lobulated mass and the inferior left breast.

36:30

This was going to be given a category three, um, based on this imaging.

36:34

But you can see on the T2 all the way on the right there, um,

36:37

that it really has the sation. It's very, very bright.

36:42

It looks like a fibroadenoma or maybe it's a funny lymph node,

36:45

but either way it's a benign finding.

36:47

So the impact of T2 sequence on the abbreviated impo, uh, mr.

36:51

It affected management in about 2.5, uh,

36:54

percent of patients averted biopsy and 0.1% six month

36:59

follow-up and about the same and additional evaluation in one patient.

37:02

It did not affect the interpretation in any cancer case.

37:06

And so we really need to investigate this more. Okay,

37:10

tips for implementation and the very getting towards the end.

37:15

So important. This was an issue.

37:17

There is no billing code right now for abbreviated mr.

37:21

So we needed to create a self-pay and we had to work very carefully with

37:26

legal because the patients have to sign an awareness that they have to pay out

37:31

of pocket for this. So that's very,

37:33

very important and that took a long time actually at our institution. Again,

37:37

I emphasized this before, working with your techs on scan efficiency.

37:41

Do those recons after the patient's off the table so you can get the next

37:44

patient in and turn it over quickly.

37:47

Work with scheduling to triage the patient so they get to the appropriate

37:51

protocol. That's very, very important. Do they actually, um,

37:55

qualify for a full protocol based on risk? I'm sure you uh,

38:00

may have heard that there's a lot of legislation going on to allow more women

38:04

with dense breasts,

38:05

particularly extremely dense breasts to have insurance coverage for.

38:10

Um, uh, full protocol mr. Um, that's happening across the country.

38:15

It's happening, uh, pretty quickly in Pennsylvania.

38:17

So we're gonna have to be very careful in our triaging of patients. Um,

38:22

recommend risk assessment at the time of screening.

38:24

So you get women into the right protocol, the full versus the abbreviated.

38:29

And we really ask these patients to bring prior mammograms if they're out of our

38:33

network and we don't have their mammograms cuz it does help to correlate the

38:36

mammogram with the mr, um, in interpretation of any breast. M r I.

38:42

Here's an interesting, um, paper that came out fairly recently about how,

38:47

um, much are women willing to pay for breast M r I. And again,

38:52

this was a single institution survey done in 2019 to 2020.

38:57

Um, asking about both, um,

38:59

contrast enhanced mammo and M R I and how much they'd be willing to pay for

39:03

these. Contrast these, um, you know, dynamic studies, um,

39:06

they had a pretty good completion rate and 53, uh,

39:10

percent of the women who completed this had dense breasts.

39:13

And a good group of them, almost 14% had had a prior contrast study. Um,

39:18

35% were satisfied, satisfied with mammography for screening.

39:22

And the major negative or neutral, um,

39:25

part about these extra studies were contrast claustrophobia, false positives,

39:30

of course, you know, X-ray exposure with the contrast enhanced, uh, mammo,

39:34

not with MR of course, um, and having an iv, et cetera.

39:38

So things to think about, but the majority just over, um,

39:42

about 55% were willing to pay at least 250 to $500 out of pocket for

39:47

M r I. Um, when they did not meet the criteria for insurance reimbursement.

39:52

I will tell you that our site, we looked at, uh,

39:56

reimbursement for or average out-of-pocket payment for full, uh,

40:01

MR as well as supplemental screening with, um, ultrasound, et cetera.

40:07

And in general, things were around 300 or a little bit over 300, 3 25.

40:12

So we went low and I was very lucky to have a, um, collaborative chair.

40:16

We charged 2 99 out of pocket, um, at our site for our abbreviated protocol.

40:21

I'm not sure that makes us any money, but, um,

40:23

it does get a lot of abbreviated MRS. Performed.

40:26

These are questions at scheduling you might be interested in.

40:29

And these are things are,

40:30

we've worked with our schedulers to try to triage patients to the right, um,

40:35

study. You know, they may, uh, really be eligible for a full protocol. Um,

40:40

they may not wanna pay out of pocket. We do right now have a grant for, um,

40:44

African-American women, um, to get abbreviated Mrs. For free.

40:49

That's because we were finding there were access issues. Um,

40:52

and that's an ongoing project. But anyway, um,

40:55

making sure that they have dense breasts, um, et cetera.

40:58

Just questions that you may be interested for your reference.

41:02

And we made this card. Um, we've had different, uh, variations of this card,

41:07

but this is an information card that we put in, uh, primary care, uh, offices,

41:12

referring physicians offices. We have them in our waiting room,

41:16

in our mammo suite so that if women want to ask questions and wanna read

41:20

about this, and then if we, um,

41:22

meet a woman for a diagnostic or first screen and we really think she would

41:26

benefit from this, we hand her this card and it tells you how to schedule, um,

41:31

and answer some of the very typical questions. And we worked with, um, you know,

41:36

our, uh, our department and advertising for this.

41:41

Just some numbers over time. You can see we started in January, 2016.

41:46

On the left I have by month, you can see the dip there. Um,

41:51

right here. This is covid, like nothing was happening for those two months,

41:55

unfortunately. Um,

41:57

and then we started back up and here we are through May, 2023.

42:01

On the right is the studies by year again,

42:04

went down a little bit during covid years. Um,

42:06

so you can see we do a pretty brisk volume, um, of these in our network.

42:12

So in summary, um, I think, I hope I've demonstrated to you to,

42:16

to you that, uh, Mr Breast, MR is the most sensitive,

42:19

most modality for the detection of breast cancer.

42:22

And I really believe that abbreviated protocols have a very similar sensitivity

42:27

to the full protocols. And I think there may be an improvement in specificity,

42:31

but we need to get more data on that. But I, I, I think I actually may be there.

42:36

So abbreviated, uh, Mr. Breast, Mrs.

42:39

Have appro improved efficiency and maintain accuracy and

42:44

therefore may allow more women access.

42:47

And I think that is so important. Um,

42:49

I think this is going to be the supplemental screening modality of the future.

42:53

I do think you still need the mammogram though,

42:55

and preferably OT tomosynthesis to go with it.

42:58

So that's the end of this. I'm gonna stop sharing.

43:02

I'd love to hear any questions you might have.

43:07

Um, I know there's a, a chat.

43:13

So let's see.

43:14

Yeah,

43:14

at this time we're gonna open the floor for any questions from our audience.

43:17

So go ahead and flop your question in the q and a box. And Dr. Conan,

43:22

it's usually at the bottom. Do you see the q and a? I see it. There we

43:26

Go. Thank you. Yeah. Okay. Um, how much is charge? So 2 99.

43:30

And again, I don't think we're making money on that,

43:34

but we really wanted to get our numbers and do some good solid research. Um,

43:38

again, that 2 99 really depends on efficiency of your texts. Um,

43:42

you can see from that recent publication I showed you that that many people are

43:47

willing to pay more. Um, but I think you have to work with your institution,

43:50

decide what's right,

43:51

and hopefully sometime soon we'll have a true, you know,

43:55

insurance coverage and reimbursement for this. Um, but good question. Um,

44:00

next one was not all cancers are enhancing and may just, um, uh,

44:05

be T2 abnormal. Um, I'm not sure

44:12

I understand that this is really depending on, um, enhancement. Um,

44:16

there are some cancers like, um, triple negatives,

44:20

but they do tend to have a little bit of enhancement.

44:23

Some cancers that are necrotic may only have a rim of enhancement, um,

44:27

and a t2 bright central area. Um, that's true,

44:31

but I still think they look irregular and strange. Um, so I, I think, um,

44:36

I think this in combination with mammography to find those calcific

44:41

ones that aren't enhancing. Um, it's a great con.

44:45

It's the best we have and I think it's a very good combination. Um,

44:48

how often good question are you recommending?

44:51

Abbreviated more so here I am, uh, I'll speak from personal experience.

44:56

I'm having them every other year, so I'm average risk,

45:00

but I have that other dense breast thing going on. Um, I,

45:04

so I think that at least every two years, but I,

45:08

I lean towards premenopausal, particularly very dense women,

45:11

having them yearly myself. Um, so again,

45:15

we don't have that work going on.

45:17

We're beginning to accrue it from the sequential data that I showed you,

45:22

and I look forward to other sites, uh, mirroring that and combining data.

45:28

Um, next question is, uh,

45:32

what are your criteria for recommending, um,

45:34

the abbreviated MR again right now before the new legislations goes in it's

45:39

average risk. So it's gotta be less than, you know, 20%.

45:42

They can't qualify for a full protocol MR based on risk,

45:46

and they have to have heterogeneously or extremely dense breast.

45:50

Now that will change when the new legislation comes in and those extremely dense

45:55

breasted women will be allowed to have full protocol.

45:58

And that also in our states could include heterogeneously dense with another

46:02

risk, even though they may not equal 20% by classic risk character, you know,

46:06

risk analysis. Um, but right now, and what I've presented to you already,

46:10

our data that we've published is average risk by

46:16

whatever risk assessment they're using,

46:19

but not including density plus heterogeneous or extremely dense

46:24

breasts. Um, and someone asked T2 Stir in dense breast.

46:29

Yes. Um, and again, I showed you the data for that. I hope, um,

46:32

you probably asked that before I got to that section. Um,

46:36

who qualifies for abbreviated mr. Again,

46:39

it's heterogeneous and extremely dense breast right now that's gonna change his

46:43

legislation roles and in different cities in different areas. Um,

46:48

do you think it's important to recommend abbreviated MR in women with dense

46:52

breast with negative mammograms and ultrasound? Yes, I do. I think,

46:57

um, ultrasound, even if it's abus or handheld,

47:01

whatever your preference is,

47:03

I don't think you're gonna see all of these lesions that you can see because of

47:07

the enhancement, the dynamic physiologic imaging. Um,

47:11

I think I showed you an example of that, so I may be biased, but,

47:16

um,

47:18

I don't think doing screening ultrasound adds a thing to an

47:23

MR screen and I show the data for that.

47:25

So I certainly would not do ultrasound and Mr,

47:29

I would just do mammography and ultrasound mammography to catch the

47:32

calcification lesions that you may not see on mr for some reason an MR

47:37

defined the masked buried and dense breast tissue enhancing

47:42

lesions. Um, has abbreviated MR been used, uh,

47:46

in follow up for post breast cancer, uh, surveillance patients? Um,

47:50

I think there is some data evolving.

47:53

I'm sorry I can't quote you numbers or anything, uh,

47:55

like that most of those patients do qualify for insurance reimbursement. Um,

48:00

insurance coverage for, uh, for MR though, um,

48:05

how much contrast we're using, the same amount of contrast, um,

48:08

that we would use for a full, um, and, uh, we're using,

48:13

um, gabapentin. Um,

48:16

what is your recommendation of full MR in moderate and high risk women? Um,

48:22

yes, uh, again,

48:24

they have to meet a risk profile and I think you have to be very careful in how

48:28

you calculate their risk and work with your clinicians to make sure they're

48:33

using the right ones. Some of the risk, um, algorithms,

48:38

um, have been developed on non-diverse populations. Uh,

48:43

so you have to be careful about which one you use.

48:45

There are some that are better than others. That's a whole nother lecture. Um,

48:49

so you should talk to your cancer center and make sure you're optimizing because

48:52

if you do the same, the same woman with different risk algorithms,

48:56

one of them may make her greater than 20% lifetime risk. Um,

49:00

so I think you have to work on that and be creative. Um,

49:06

uh, what is your recommendation of full protocol, Mr. Mod?

49:10

I think I just did that one. Um,

49:12

is the turnaround time for the report any different from full mr? No,

49:17

it really looks exactly the same. Um, you know,

49:21

and the report is a birads based, um, you know, we,

49:24

we do specify what kind of study she had,

49:27

but the turnaround time and all of that is, is, um, the same and the reporting,

49:32

um, how do you word that recommendation? I'm not sure what that means.

49:37

Um, okay. Uh,

49:41

is MR going to be the gold standard for diagnosis in breast imaging for dense

49:44

breasted women? Again, you know, I think many people, I think if you, you know,

49:49

listen to Christiana Cool who's done such amazing research and is a wonderful

49:53

lecture, um, she thinks, you know, Mr.

49:56

Is is the be all and end all and great. I I still like mammography.

50:01

Uh, it's cost effective and easy to do. Yes, it's radiation, but um,

50:05

I think the combination is, is best. Um, I don't mean to quote her, she's not.

50:09

She's just very Mr. Pro and i I am too. Um,

50:14

your thoughts on screening for women with family history of breast cancer beyond

50:18

first degree relative currently limited to the first degree family history. Um,

50:22

so this is very important. That's that question again gets at,

50:25

and that's a whole nother lecture on different risk assessment, um, algorithms.

50:30

There are some risk assessments that use more than just the first degree

50:34

relatives and they're now even risk assessments that include breast density

50:39

in them.

50:40

And so I think you have to really have a group discussion with your site and

50:44

with your medical oncologist, et cetera, about the best, um,

50:49

risk assessments. And who's gonna do that ideally? Um, I think we would, um,

50:54

do a great benefit to patients and our referring physicians if we could do a

50:57

good risk assessment at the time of screening mammography. Um,

51:02

how do you, uh, word the rep the recommendation in your report for an,

51:07

um, abbreviated mr. Yes, so we get them card out.

51:11

This is if a woman has a dense breast and she's got a non-actionable screen or

51:15

diagnostic, but we think she would benefit,

51:17

we hand her the card and sometimes I will, even if she's a screener,

51:21

I may even put it in the report or I may, um,

51:24

send a direct message to her referring physician.

51:27

We actually have a really cool research project, um,

51:30

just starting up that is nudges, uh, to both the patient through our,

51:35

uh, reporting system and the referring physician about the use of abbreviated MR

51:40

for women we feel qualify. Um,

51:44

who does the risk triaging the attending physician or the radiologist?

51:48

So we try to do some risk triaging, um, at entry to screening.

51:53

And, um, then also it's done in the primary care and other referring offices.

51:57

Um, so it's not by done by the radiologist. However,

52:00

if I think a woman really could benefit from, um, abbreviated MR or full MR.

52:05

And I look at her history and her medical chart,

52:08

I may discuss that with her as well. Um,

52:12

have we compared the sensitivity of uh, C E M to fast Mr. No. Um,

52:16

I think that's great. C e m is also, um,

52:19

great because it's a dynamic physiologic, you know, vascular imaging,

52:24

um, tool for us. We're very fortunate that right next to our screening area,

52:29

our, our mammographic suite, um, of screening and diagnostic,

52:33

we have six MR units. So we have patients coming in, getting both. Um,

52:37

we don't have other rooms that we did contrast for a while. Um,

52:41

as part of a trial about seven years ago,

52:44

there were a couple cancers that we didn't see on contrast, um,

52:48

mammo that we saw on, um,

52:50

MR cause of the depth of field of view on the mr. Right,

52:55

you get to see all the way back to the chest wall,

52:58

you get to see higher in the axilla. Um,

53:00

so I have a little bit of bias and field of view, but I don't know, um,

53:05

we basically haven't compared that, um, carefully.

53:07

That was a small number of patients. Um, uh,

53:11

someone's asking me which risk algorithm do we use? Oh,

53:14

that's a political question. Um, I'm fond of the tire kuzak eight,

53:20

uh, because it includes breast density honestly. Um,

53:23

but different risk assessments are used throughout our network and different

53:28

risk assessments are used in the primary care offices. Um,

53:31

I can tell you the out of box one that comes with our reporting system, um,

53:35

is basically the Gail,

53:36

which again is not great at dealing with diverse populations or getting a deep

53:41

family history beyond first degree relatives. Um, so that's a hot, hot topic.

53:46

Um, yeah, sorry, I can't answer more of that. Um, what's the,

53:51

um, interval of M R I and postoperative surveillance? So again,

53:57

postoperative cancer patients, um, it depends on the,

54:02

um, you know,

54:03

on the age of the patient and the type of cancer and the type of density and

54:07

it's very subjective, but, um,

54:10

and I can't tell you how often I think for women that have aggressive tumors and

54:15

are very dense yearly, um,

54:17

many of them do qualify for insurance reimbursement for that patient comfort

54:22

would be one of the important pros for MR for screening perhaps every two,

54:26

two years. Um, yes, that was a statement, not a question, I guess.

54:31

Um,

54:33

in any case you feel need to change abbreviated to full mr is there any case

54:38

in which, um, I haven't seen any cases. Um,

54:43

and I really wanna collect the data on the specificity,

54:48

um, of our abbreviated mr. The question is,

54:50

are there women who really deserve the full MR over the abbreviated? Um,

54:56

that's a really tough question. Um, from the data,

54:59

I haven't seen it in the cases that we've done abbreviated mrs.

55:04

Uh, there's the diffusion, which I like diffusion,

55:08

that comes in a full mr. So that's, uh, you know, a bias.

55:11

The one thing I didn't mention in this talk was, um,

55:16

I talked about we inject and then we wait 20 to 30 minutes,

55:20

20 to 30 seconds after injection for our one post contrast and our

55:25

abbreviated protocol.

55:27

Now we've noticed that some women had very low background paral enhancement,

55:32

B P E,

55:33

and we've actually now required our technologists to put an R OI

55:38

on the aorta, believe it or not, um,

55:41

to make sure that there is contrast coming out, you know,

55:45

being circulated because I think that we were, um,

55:48

in some of our older patient populations with poor ejection fractions,

55:51

we might have been scanning a little early and that worries me about sensitivity

55:56

and and cancer detection in that population.

55:59

So that's something we're working on.

56:00

I don't have a full answer for you right now, but now as of about the last year,

56:05

I've required the technologist to document an r o i so that I can see contrast

56:10

coming out. Um,

56:13

is there a leverage in court of law for abbreviated MR compared

56:17

to full if we list, um, if we miss a lesion?

56:22

Interesting question. Question. And I don't have an answer to that.

56:24

We haven't had any. Um, yeah, I hope we don't, uh,

56:29

have any interaction with that kind of, uh, question. So sorry,

56:32

I don't have an answer for that one. Um,

56:35

in which cases do you recommend in full breast m r imaging again? Um,

56:40

you know,

56:41

if they right now are covered by insurance to get the full breast mr,

56:46

that's what we do. Um,

56:47

because it could be less out of pocket now some of them have to pay more out of

56:51

pocket, um, but we still do the full, um, MR for those women, if they qualify.

56:57

Has the increased MR volume and subsequent needed biopsies caused any scheduling

57:02

or volume issues? Ooh, that's a good one.

57:05

That's an anonymous attendee. Yes. Um, we have, uh,

57:10

our volume has increased significantly and we have had some

57:15

backlog. I think that's been across the country,

57:17

particularly with c and people not getting studies that they needed. Um,

57:22

you know, I call it the COVID resurgence, um,

57:25

but now we've opened slots, extended hours and weekend hours. Um, but yes,

57:30

if you look at how many Mrs.

57:32

Our Breast imagers read these days compared to prior days, it's up.

57:36

But it's not only because of the abbreviated,

57:39

it's just Mrs being used more often. So good question.

57:41

Whoever my anonymous attendee is,

57:44

you can contact me after and we talk more. Um, thank you very much. Thanks.

57:49

Uh, would you use, uh, contrast enhance mammo for second look imaging post? Mr.

57:54

I wouldn't. I would try tomo and m and ultrasound for those patients and then go

58:00

directly to, uh, MR Biopsy if nothing is seen. And again,

58:03

we try not to do too much second look,

58:06

you really have to really think you can find it like those masses I showed you.

58:09

Um, with ultrasound, uh, detection, um,

58:14

you know, that takes time. It delays things. Um,

58:18

if we really think there's a suspicious area, we tend to,

58:21

and we don't think we're gonna see it with much likelihood and,

58:24

and tomosynthesis or ultrasound, we go directly to Mr. Biopsy. Um,

58:31

which post-processing software do you use? Ooh,

58:35

I'm embarrassed to say we use, um,

58:39

we don't have cad, if that's what you're asking on Mr.

58:43

Right now. Uh, we grew up without it and we just don't have it.

58:46

We do a lot of CAD and AI in mammography, um,

58:51

but we're not using it right now. We, we, um, yeah,

58:55

we have Siemens units and we scan, uh, we, we review them on sectra,

59:00

um, and report in Epic. Um,

59:03

would you recommend full breast Mr for lobular carcinomas?

59:07

That's a really interesting question and that's a good research. Um, you know,

59:11

go back, we haven't had enough interval cancers or detections,

59:15

but if we looked at the subgroup of, of lobular, as you all know,

59:18

they enhance slowly sometimes. And they're not often masses.

59:22

They're kind of creepy crawly. Um, I can't answer that directly. Um,

59:26

but you don't know if she's gonna have it or not.

59:28

So if she doesn't qualify for the full mr, you're gonna do an abbreviated mr.

59:32

Um, but something to look at. Thanks for asking that. Um,

59:36

how often do you confer to full? When we see a le uh, a lesion, um,

59:41

we never convert a abbreviated to a full.

59:44

We just go ahead and biopsy it if we see it or do a second look ultrasound. Um,

59:49

so, um, and our diffusion is only performed on our full, not on our abbreviated,

59:54

cuz it takes so long. I mean,

59:55

it's a longer sequence is a sensitivity different with high background

59:59

enhancement. Um, you know, again, the most of that high background enhancement,

60:04

you're, you're gonna see the avidly enhancing lesions first. You know,

60:08

um, yes, you do see some splotchy enhancement and all of that,

60:12

but that really masking background enhancement tends to be on delayed imaging.

60:17

So we really haven't seen sensitivity differences. Um, but again,

60:20

good thing to look at. We need more data. Um,

60:24

if there are enough volume of cases,

60:26

having second m r I unit to shorten time also and have t2 uh,

60:30

weighted images included, what does that mean?

60:32

If there are enough volume of cases having second MR Unit shortened time. Hmm.

60:37

I'm not sure what that means. And have T2 weighted images. You know, I,

60:41

I love the t2 s I think they make things very, um, easy to read, um,

60:46

and quick answers. So I prefer to keep them, um, again, you know,

60:51

when you look at our whole turnaround time and our efficiency with the

60:54

technologists working, yeah, you could cut out four minutes,

60:57

but how long does that really cut out? It's getting her on the table,

61:00

getting her comfortable, getting her breasts in the coils. You know,

61:05

those are the things that really take time. Um, uh, I think a four.

61:10

I mean, maybe we could, we could shorten that and something we should consider,

61:14

but, um, you know, I think running a like eight minute one isn't bad.

61:19

Um, how much are you charging out of pocket? I think I said that.

61:21

I hope I don't get in trouble for it, but it's 2 99,

61:24

so come to Philly if you want one. And I think that was the last question. Um,

61:29

and I think we're, oh, we're out of time too.

61:32

That was the last question. There were 30 of them, uh,

61:35

that you just breezed through, so that was a marathon.

61:38

That's, people are interested. That's good. Yeah,

61:41

Totally. Um, and thank you so much for the lecture and for everyone,

61:44

for asking such wonderful questions and,

61:47

and participating in this new conference.

61:49

You can access the recording of today's conference and all our previous new

61:52

conferences by creating a free online account.

61:56

And please be sure to join us next Thursday,

61:58

June 29th at 12:00 PM for a lecture with Dr.

62:02

Jonathan Samit on approach to pediatric bone lesions.

62:05

You can register for this free lecture@mriline.com and follow us on social

62:09

medias for updates on future NOOM conferences. Thanks again, Dr.

62:13

Conein and everyone, have a great day.

62:15

Thank you all.