0:00

So, I'm going to go through some of the

0:02

background history here about MR, and the

0:05

biggest trial really that I think, um,

0:07

well, the most important one early on, was the EVA trial.

0:10

This was Christiana Kuhl.

0:11

It was very famous for all sorts of breast MRI.

0:13

Mr.

0:13

Um, and this was, um, um, about

0:17

almost 700 asymptomatic women.

0:19

These were high-risk women, greater

0:21

than 20 percent lifetime risk

0:22

who underwent annual screens.

0:24

They had clinical breast exam, mammography,

0:26

ultrasound, and this was full protocol.

0:28

And were not abbreviated yet.

0:30

These were read independently of those studies

0:32

and in different combinations together.

0:34

And this was a really beautiful study and looked

0:37

at, um, you know, follow-up as well for outcomes.

0:41

So, mammography found

0:42

cancer detection yield of 1,000.

0:45

This is again a high-risk population.

0:48

Ultrasound 6, mammo plus ultrasound

0:50

because it's complimentary 7.

0:53

MRI almost 15, MRI plus ultrasound catches

0:57

that no more by adding ultrasound to MRI.

1:01

That's a very important note.

1:03

Mammography, however, adds to MRI, because

1:07

you can imagine very small early DCISs that

1:10

are only small areas of calcifications.

1:13

We may not see those as enhancing lesions on MRI.

1:16

Adding ultrasound again to MR

1:18

and mammography, no additional cancers detected.

1:22

So MR combined with mammography finds

1:25

the cancers, that's the way to go.

1:27

So, um, let me, I have something blocking.

1:31

There we go.

1:32

I hope you all can see, there was

1:33

something blocking my screen anyway.

1:35

Okay.

1:35

So, conclusion for screening high-risk

1:37

women again, high-risk women, these are the

1:39

outcomes there and you can see clearly that MR.

1:42

45 00:01:43,114 --> 00:01:44,635 plus mammography has the,

1:44

uh, the highest performance.

1:51

Then came the ACRIN 6666 trial.

1:54

This was screening ultrasound.

1:55

Wendy Berg's trial.

1:56

Very important.

1:57

Um, adding ultrasound screening to

2:00

women with non-actionable mammograms.

2:03

And these were mostly women with high risk.

2:07

Um, at least half of them had prior breast cancers

2:10

and the other half were considered high-risk

2:12

based on familial history and things like that.

2:15

Um, interesting at the very end of this,

2:17

after 3 rounds of non-actionable screens with the

2:20

ultrasound and mammography, MRI was added at the very end.

2:24

So let's look at these results.

2:26

Here's the mammography alone round 1 versus

2:29

round 2, and these are sequential rounds.

2:32

Ultrasound only, you can see the cancer detection.

2:35

Mammography plus ultrasound better

2:36

because they're complementary.

2:38

Supplemental ultrasound yielded

2:41

5.3 per 1,000 cancers, um, cancer

2:43

detection in the first year.

2:45

Additional in the second year, a seven

2:48

to eight absolute increase in recall.

2:50

Again, specificity is an issue with ultrasound.

2:53

And after three rounds of combined screening,

2:56

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

2:59

Women hate short-term follow-ups.

3:01

Category threes. They hate them.

3:03

So let's see about the MRI.

3:05

So here's the mammography alone.

3:07

Cancer detection rate at 8.2.

3:08

80 00:03:08,640 --> 00:03:11,480 This is overall and this is mammography plus ultrasound.

3:11

It goes up a little bit.

3:13

Add the MR 26.1

3:14

for a difference of a decisional almost 15 per

3:17

1,000 screen cancer detection mammography plus MR again,

3:22

very, very good versus mammography alone MR alone.

3:25

So combining MRI and mammograms are the way to go.

3:32

After three rounds of negative mammography

3:33

ultrasound, 7 per 1,000 additional cancers.

3:38

That's about 1.5%.

3:39

91 00:03:40,574 --> 00:03:42,525 Again, these are high risk for women with prior

3:42

breast cancer history, a four times greater cancer

3:45

yield than adding just ultrasound to mammograms.

3:48

So ultrasound screening as a supplement is

3:50

very, very common, and it does find cancers,

3:53

but it's not nearly as impactful as MRI.

3:56

So no doubt, MR with mammography is the way to go.

3:59

Here's just an example.

4:00

This is a woman who's extremely dense.

4:03

Um, she had a negative mammogram.

4:05

She even had, um, an ultrasound.

4:07

And you can see the duration is

4:09

October of 2012 and then March of 2013.

4:14

Here's her MRI of the right.

4:15

Here's her MRI of the left so diffuse enhancement.

4:19

This is not something that might be

4:20

detected on ultrasound because it's larger

4:23

than the field of view, even whole breast

4:25

ultrasound, but diffuse diffuse enhancement.

4:29

And this was.

4:30

An extensive invasive ductal carcinoma.

4:34

So what about cancer biology?

4:36

Always important.

4:36

Are we just finding slow

4:38

growing, you know, low stage.

4:40

This was an important study by Janice

4:42

Sung et al., including Chris Comstock,

4:44

a retrospective review of high-risk women.

4:47

What kind of cancers were found

4:48

by these different modalities?

4:50

Most of them were detected by MR in this group.

4:53

Um, a smaller amount by mammography,

4:55

and there were actually 12 invasive,

4:57

I'm sorry, interval cancers as well.

5:00

And I love this graph, because what

5:02

you can see along the bottom is

5:04

increasing tumor histologic grade.

5:07

So worse, more aggressive.

5:09

DCIS.

5:10

Low grade is all the way there

5:11

on the left at the bottom.

5:12

Then it gets intermediate

5:13

grade DCIS, high grade DCIS.

5:16

Then we get microinvasive invasive

5:18

ductal carcinoma with a low grade,

5:20

intermediate grade, and high grade.

5:22

And look at these different curves.

5:24

The MR screening has, uh,

5:27

that's the mammogram line, sorry,

5:29

has decreasing, um, aggressive biologies.

5:33

Finds more DCIS

5:34

143 00:05:34,550 --> 00:05:34,720

5:34

145 00:05:35,280 --> 00:05:36,860 less high grade ones because those

5:36

high grade ones sometimes are round

5:38

balls like triple negative cancers.

5:40

But look at the MRI.

5:41

150 00:05:41,910 --> 00:05:42,320

5:42

increasing tumor histology.

5:44

And those are the ones we

5:45

really, really want to find.

5:46

I mean, we want to find them all in my mind,

5:48

but those aggressive tumors are the ones

5:51

between screens that can cause problems.

5:54

So more cancers with MRI.

5:55

159 00:05:55,730 --> 00:05:55,940

5:55

And more often invasive and higher

5:57

grade than those that mammography.