乳腺磁共振成像课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,山东省医学影像学研究所,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,乳腺磁共振成像,MRI OF BREAST,史浩,山东省医学影像学研究所,8/27/2024,1,乳腺磁共振成像MRI OF BREAST史浩9/2/202,PREFACE,8/27/2024,2,PREFACE9/2/20232,MAMMOGRAPHY,8/27/2024,3,MAMMOGRAPHY9/2/20233,PITFALLS,The sensitivity is between 69% and 90%.,The specificity ranges from 10% to 40%.,Tumours may be missed because of poor mammographic technique or observer error,or the size and nature of the lesions relative to the surrounding breast,tissue, which may obscure them.,8/27/2024,4,PITFALLSThe sensitivity is bet,ULTRASOUND,8/27/2024,5,ULTRASOUND9/2/20235,PITFALLS,US has limitations as a screening modality because microcalcification in ductal carcinoma,in situ,may not be identified.,The false negative rate is ranging from 0.3% to 47% in some series.,It is difficult to ensure that the entire breast has been imaged.,US is time consuming.,8/27/2024,6,PITFALLSUS has limitations as,MRI,8/27/2024,7,MRI9/2/20237,ADVANTAGES,Excellent soft tissue resolution,Tomographic imaging,Multiple orientations,High spatial resolution,Lack of ionizing radiation,Grading the cancer of breast,8/27/2024,8,ADVANTAGESExcellent soft tissu,DISADVANTAGES,Lower sensitivity to calcification,Expensive Examination fee,Longer examination time,Infection of heart movement and respiration,8/27/2024,9,DISADVANTAGESLower sensitivity,EXAMINATION INDEX,钼靶或超声不能确诊的病灶,区分术后疤痕和肿瘤复发,要保留乳腺的乳腺癌患者，查找其它隐藏肿瘤，明确肿瘤范围，确定手术区域,评价隆胸术后硅树胶植体的完整性及乳腺病变情况,8/27/2024,10,EXAMINATION INDEX钼靶或超声不能确诊的病灶9,MRI TECHNIQUE,8/27/2024,11,MRI TECHNIQUE9/2/202311,COILS,dedicated breast coil,single or double breast mode,8/27/2024,12,COILSdedicated breast coil9/2/,EXAMINATION TIME,After menopause,No time request,Before menopause,Sixth to Sixteen days of the menstrual cycle,Or avoiding six days before and after menses,8/27/2024,13,EXAMINATION TIMEAfter menopaus,POSITION,The prone position will decrease the amount of respiratory motion artifact.,Minimal compression applied within the coil will decrease motion artifact.,8/27/2024,14,POSITIONThe prone position wil,PHASE-ENCODING DIRECTION,The phase encoding direction should not pass anterior to posterior, but from left to right,to ensure that cardiac activity is not projected over the breast.,8/27/2024,15,PHASE-ENCODING DIRECTIONThe ph,SATURATION & GATING,Saturation zone is located behind thoracic wall,Cardiac and respiratory gating,8/27/2024,16,SATURATION & GATINGSaturation,SCANNING PLANES,Transverse plane,Coronal plane,Sagittal plane,8/27/2024,17,SCANNING PLANESTransverse plan,CONVENTIONAL SEQUENCES,T1WI,T2WI,STIR (Fat suppression sequences),8/27/2024,18,CONVENTIONAL SEQUENCEST1WI9/2/,SPECIAL SEQUENCES,3D FLASH (fast low angle shot),PWI (Perfusion Weighted Imaging),CSI (Chemical shift imaging),8/27/2024,19,SPECIAL SEQUENCES3D FLASH (fas,SCAN PARAMETERS,Thickness: 2mm5mm,Gap: 03mm,Matrix: 256,256,FOV: 30cm40cm,Acquisition time: 13,Scan time: 3min5min,8/27/2024,20,SCAN PARAMETERSThickness: 2mm,MRI ENHANCEMENT,8/27/2024,21,MRI ENHANCEMENT9/2/202321,SIGNIFICANCE,There are an obvious overlap between benign and malignant lesions in plain MR scanning.,The enhancement can increase the distinction between the lesion and surrounding normal tissue.,Sensitivity and specificity of the diagnosis would be markedly increased.,8/27/2024,22,SIGNIFICANCEThere are an obvio,PRINCIPLE,Intravenous gadolinium passes into the extravascular space and accumulates in tissues with rich vascularity.,8/27/2024,23,PRINCIPLEIntravenous gadoliniu,CONTRAST AGENT,Gadolinium (Gd-DTPA),Intravenous injection,Dose: 0.1 mmol/kg 0.2 mmol/kg,Speed: 2ml/s 3ml/s,8/27/2024,24,CONTRAST AGENTGadolinium (Gd-D,NORMAL PATTERNS,Normal glandular breast tissue enhances relatively slowly over 10 min following the injection of iv gadolinium.,8/27/2024,25,NORMAL PATTERNSNormal glandula,BENIGN LESIONS,不强化,边缘光滑或分叶状结节强化,强化结节内呈分隔状,弥漫点状强化,8/27/2024,26,BENIGN LESIONS不强化9/2/202326,MALIGNANT LESIONS,不规则或毛刺状结节强化,环状强化,导管状强化,8/27/2024,27,MALIGNANT LESIONS不规则或毛刺状结节强化9/,NORMAL STUDY,8/27/2024,28,NORMAL STUDY9/2/202328,NORMAL BREASTS,8/27/2024,29,NORMAL BREASTS9/2/202329,FINDINGS,乳腺内腺体、导管和脂肪结缔组织分布和比例决定乳腺的,MR,表现特点,腺体型（腺体实质为主，多见于青年女性）,T1WI,和,T2WI,呈均匀等信号，周围可见高信号脂肪围绕,T2,压脂序列显示导管呈树枝状并向乳头汇集,脂肪型（以脂肪为主，多见于老年女性）,T1WI,和,T2WI,以高信号为主，仅于乳头周围可见少量残存等信号腺体影,T2,压脂序列示导管分布稀疏,中间型（多见于生育过的中年女性）,表现间于上两型之间,8/27/2024,30,FINDINGS乳腺内腺体、导管和脂肪结缔组织分布和比例决定,NORMAL STUDY,腺体型,脂肪型,中间型,8/27/2024,31,NORMAL STUDY腺体型脂肪型中间型9/2/20233,CASES,8/27/2024,32,CASES9/2/202332,FIBROADENOMA,单发或多发,形状规则，呈圆形、类圆形、分叶状,边界清晰，与周围组织分界清楚,可见包膜,T1WI,呈低（或等）信号,T2WI,呈等或略高信号,增强后以纤维成分为主时强化较弱，以腺样成分为主时呈较明显强化,8/27/2024,33,FIBROADENOMA单发或多发9/2/202333,FIBROADENOMA,Pre-contrast,Post-contrast,mammogram,Fibroed fibroadenoma,8/27/2024,34,FIBROADENOMAPre-contrastPost-c,FIBROADENOMA,Pre-contrast,Post-contrast,Adenomatous fibroadenoma,8/27/2024,35,FIBROADENOMAPre-contrastPost-c,FIBROADENOMA,T1WI,T2WI,CONTRAST,Adenomatous fibroadenoma,8/27/2024,36,FIBROADENOMAT1WIT2WICONTRASTAd,PROLIFERATION,T1WI,呈低信号,T2WI,根据水分的多少而表现不同，水分多信号高，水分少信号低,增强后呈较广泛轻度斑片状强化,表现不具特征性,8/27/2024,37,PROLIFERATIONT1WI呈低信号9/2/20233,PROLIFERATION,SE 400/30,SE 2400/90,Mammogram,Focal fibrotic fibrocystic condition,8/27/2024,38,PROLIFERATIONSE 400/30SE 2400/,PROLIFERATION,mammogram,3D FE 40/14/50,enhanced image,Nonproliferative fibrocystic changes,8/27/2024,39,PROLIFERATIONmammogram3D FE 40,PROLIFERATION,3D FE 40/14/50,enhanced,delayed,mammogram,Proliferative changes,8/27/2024,40,PROLIFERATION3D FE 40/14/50enh,PROLIFERATION,Precontrast T1 3D FLASH,Gd-DTPA-enhanced image,mammogram,Focal proliferative changes,8/27/2024,41,PROLIFERATIONPrecontrast T1 3D,CYST,T1WI,上单纯性囊肿呈低信号（取决于囊内蛋白含量）复杂性囊肿囊内常含有血液成分，可呈高信号表现,T2WI,一般呈高信号,增强后病灶无强化，如伴发感染时可出现周边强化,不规则或结节状周边强化提示为肿瘤坏死、囊肿内出现肿瘤病灶或乳头状瘤,8/27/2024,42,CYSTT1WI上单纯性囊肿呈低信号（取决于囊内蛋白含量）复,CYST,mammogram,SE 400/30,SE 2400/35,SE 2400/90,8/27/2024,43,CYSTmammogramSE 400/30SE 2400/,CARCINOMA,病灶呈分叶状、星芒状、蟹足样、毛刺状,边界不规则，与周围组织界限不清,内部不均匀,T1WI,呈低或等信号，,T2WI,呈高或等信号,不规则或毛刺状结节强化,环状强化,导管状强化,8/27/2024,44,CARCINOMA病灶呈分叶状、星芒状、蟹足样、毛刺状9/2,CARCINOMA,T1WI,横轴位平扫,横轴位增强扫描,矢状位延迟,8/27/2024,45,CARCINOMAT1WI横轴位平扫横轴位增强扫描矢状位延迟,CARCINOMA,Pre-contrast,Post-contrast,8/27/2024,46,CARCINOMAPre-contrastPost-cont,CARCINOMA,Pre-contrast,Post-contrast subtract,8/27/2024,47,CARCINOMAPre-contrastPost-cont,CARCINOMA,T1WI,平扫,1,分钟增强扫描,7,分钟延迟,病理,8/27/2024,48,CARCINOMAT1WI平扫1分钟增强扫描7分钟延迟病理9,FIBROADENOMA & CANCER,平扫,5,分增强扫描,A.,纤维腺瘤,B.,乳腺癌,平扫,5,分增强扫描,减影像,减影像,8/27/2024,49,FIBROADENOMA & CANCER平扫5分增强扫描A,DYNAMIC ENHANCEMENT,8/27/2024,50,DYNAMIC ENHANCEMENT9/2/202350,TECHNIQUE,Intravenous fleet bolus injection of Gd-DTPA,Continuous multi-times scanning with fast sequence on ROI (lesion) immediately after the injection,Observation on the lesion dynamic change and time/intensity curve,8/27/2024,51,TECHNIQUEIntravenous fleet bol,PRINCIPLE,对比剂首过（,first pass,）组织增强与,对比剂在血管结构内的分布有关,反映病灶血管丰富程度和血液灌注情况,与病变的微血管密度、管径和管壁渗透性等有关,8/27/2024,52,PRINCIPLE对比剂首过（first pass）组织增强,ANALYSING INDEX,病灶形态、大小、位置,良性还是恶性,单发或多发,病灶强化模式,(,是从中心到周围还是从周围到中心,),及早期化率,绘制时间 信号强度曲线,8/27/2024,53,ANALYSING INDEX病灶形态、大小、位置9/2/2,PATHOLOGICAL BASIS,恶性病变由于其瘤内微血管密度大，微血管基底膜极不完整，病灶局部的灌注明显增大，因此早期即可显著强化，且迅速下降,良性病变微血管密度较少且早期良性病灶常轻度或无明显强化，而随时间延长呈持续强化状态,8/27/2024,54,PATHOLOGICAL BASIS恶性病变由于其瘤内微血管,DIAGNOSTIC VALUE,增强速率（,SI,post,-SI,pre,/SI,pre,100%,）,80%,为恶性病变,8/27/2024,55,DIAGNOSTIC VALUE增强速率（SIpost-SI,PATTERNS OF CURVE,型（,增长型）（,increase/wash-in,）,信号强度迅速上升达到峰值后便呈平缓上升状态,多见于良性病变,型（,平台型）（,plateau,）,强化初期迅速上升，后期呈平台状,多为可疑恶性病变,型（,下降型）（,decrease/wash-out,）,强化信号强度在中后期呈下降趋势,多为恶性病变,8/27/2024,56,PATTERNS OF CURVE型（增长型）（incre,PATTERNS OF CURVE,8/27/2024,57,PATTERNS OF CURVE9/2/202357,PATTERNS OF LESIONS,动态增强形式乳腺癌纤维腺瘤,型,(,增长型,)6%83%,型,(,平台型,)64%11.5%,型,(,下降型,)78%1%,8/27/2024,58,PATTERNS OF LESIONS动态增强形式乳腺癌,FIBROADENOMA,T1WI,T2WI,8/27/2024,59,FIBROADENOMAT1WIT2WI9/2/202359,CARCINOMA,8/27/2024,60,CARCINOMA9/2/202360,DIFFERENTIATION,Postcontrast MIP,Early postcontrast,subtracted MR images,Early postcontrast,subtracted MR images,Timesignal intensity curve,Timesignal intensity curve,fibroadenoma,carcinoma,8/27/2024,61,DIFFERENTIATIONPostcontrast MI,DIFFUSIONWEIGHTED IMAGING,8/27/2024,62,DIFFUSIONWEIGHTED IMAGING9/2/,FUNCTIONS,To observe the microcosmic moving of water molecules,To study ADC (Apparent Diffusion Coefficient) of lesion area,8/27/2024,63,FUNCTIONSTo observe the microc,PRINCIPLE,利用,MRI,的特性序列观察活体中水分的微观运动的一种成像方法，是一种对水分子扩散运动的成像技术,DWI,使磁共振研究深入到更微观水平，反映组织空间组成信息及病理生理状态下各组织成分之间交换水分的功能状况,8/27/2024,64,PRINCIPLE利用MRI的特性序列观察活体中水分的微观运,PRINCIPLE,D,值（,Diffusion Coefficient,）,为弥散系数，反映水分子的弥散运动能力,ADC,值（,Apparent Diffusion Coefficient,）,活体水分子的弥散受多种因素综合作用，所以,D,值不能完全代表其弥散程度,8/27/2024,65,PRINCIPLED值（Diffusion Coeffici,PRINCIPLE,DWI,图,反映弥散信号的强弱,弥散快时呈低信号,弥散慢时呈高信号,ADC,图,直接反映组织弥散快慢的指标,弥散快呈白色,弥散慢呈黑色,8/27/2024,66,PRINCIPLEDWI图9/2/202366,PRINCIPLE,恶性肿瘤,细胞生长旺盛，密度高,生物膜对水分子的弥散具有明显限制作用,ADC,值小,良性肿瘤,细胞生长缓慢，细胞密度低,生物膜对水分子的弥散限制作用小,ADC,值大,8/27/2024,67,PRINCIPLE恶性肿瘤9/2/202367,METHODS,Conventional MRI scanning (T1WI, T2WI),EPI-DWI,b value: b,1,=0, b,2,=1000,Scan time: 40s,ADC=ln(Sb,1,-Sb,2,)/(b,1,-b,2,),8/27/2024,68,METHODSConventional MRI scanni,FINDINGS,恶性肿瘤,DWI,为高信号,ADC,值小，,ADC,图为低信号,良性肿瘤,DWI,为高于或略高于腺体信号,ADC,值大，,ADC,图为高信号,8/27/2024,69,FINDINGS恶性肿瘤9/2/202369,FIBROADENOMA,T2WI-FS,T2WI-FS,C+-S,C+-S,b=0,b=500,b=1000,ADC map,8/27/2024,70,FIBROADENOMAT2WI-FST2WI-FSC+-S,CARCINOMA,b=0,b=500,b=1000,T2WI FS,T1WI,C+ MIP,SAG C+,DC-C,LC,8/27/2024,71,CARCINOMAb=0b=500b=1000T2WI FS,MR SPECTROSCOPY,8/27/2024,72,MR SPECTROSCOPY9/2/202372,FUNCTION,是检测活体内代谢和生化信息的一种无创性技术,能在分子水平上反映病理情况,提供的是定量化学信息，一般以数值或图谱来表达,对这种代谢改变的潜在敏感性很高，故能提供信息以早期检测病变,8/27/2024,73,FUNCTION是检测活体内代谢和生化信息的一种无创性技术9,PRINCIPLE,利用化学位移作用进行特定化合物的分析,测量的,MR,信号通过傅里叶转换为,MR,波谱,不同代谢产物化学位移产生不同的信号强度峰值,谱的横坐标代表共振频率（单位,:,百万分率,(ppm),）,波峰信号的指标有共振频率、谱峰高、半峰高处线宽,(,表示谱峰的锐利度,),以及波峰面积等,各波峰面积与被测物中某化合物浓度的原子核数量成正比,8/27/2024,74,PRINCIPLE利用化学位移作用进行特定化合物的分析9/2,CATEGORY,当前用于医学领域的波谱有,1,、,31,、,13,、,23,和等,乳腺检查运用,1,H,和,31,P,谱，以前者效果更佳,MRS,在乳腺肿瘤的敏感性达,100%,特异性为,89%,100%,8/27/2024,75,CATEGORY当前用于医学领域的波谱有1、31、13,METHODS,Three direction planes,Decision of voxel area (1cm,3,),Adjusting field (,0.1ppm),Water suppression adjustment,Inspection of signal,After-procession,8/27/2024,76,METHODSThree direction planes9,FINDINGS,H,谱,较,P,谱敏感性更高,正常乳腺组织内不含胆碱,乳腺癌组织胆碱峰明显增高，磷酸胆碱（,Pcho,）,/,磷酸甘油胆碱（,GPcho,）比值倒置,P,谱,用于显示肿瘤和正常组织之间不同磷代谢、细胞能量和细胞间,pH,的变化信息,肿瘤细胞膜可导致磷脂化合物成分的升高,乳腺癌组织中磷酸单脂（,PME,）和磷酸二脂（,PDE,）波峰明显高于正常组织和良性病变,8/27/2024,77,FINDINGSH谱9/2/202377,FIBROADENOMA,1H MRS,COR-LC,TRA-LC,SAG-LC,8/27/2024,78,FIBROADENOMA1H MRSCOR-LCTRA-LC,CARCINOMA,T2WI FS,T1WI,C+ MIP,SAG C+,1H MRS,DC-C,LC,LC,8/27/2024,79,CARCINOMAT2WI FST1WIC+ MIPSAG,IMRI OF BREAST,8/27/2024,80,IMRI OF BREAST9/2/202380,FUNCTIONS,MRI,引导下的细针穿刺活检,MR,导向治疗，如肿瘤消融技术,手术前小病灶的定位,8/27/2024,81,FUNCTIONSMRI引导下的细针穿刺活检9/2/2023,PROCEDURE,乳腺介入专用表面线圈,导向装置,体表标志立体定向,计算机辅助下的立体定向装置,穿刺针,镍钛合金（早期）,碳纤维材料（现今）伪影更少,8/27/2024,82,PROCEDURE乳腺介入专用表面线圈9/2/202382,PROCEDURE,介入手术时机,月经结束后的第,1,周,这时乳腺腺体背景显影最弱,肿瘤显影最清楚,体位,仰卧位,俯卧位,侧卧位,8/27/2024,83,PROCEDURE介入手术时机9/2/202383,APPLICATION,临床未触及肿块，,B,超、钼靶像也呈阴性,仅,MRI,检出的乳腺病变,临床触到肿块,B,超、钼靶像检查均为阴性或可疑，,MRI,检出的乳腺病变,MRI,检查疑为多中心乳腺癌须排除假阳性,MRI,检查疑为双侧乳腺癌,需要确诊者,MRI,检查疑为良性肿瘤,需明确其良、恶性,8/27/2024,84,APPLICATION临床未触及肿块，B超、钼靶像也呈阴性,APPLICATION,8/27/2024,85,APPLICATION9/2/202385,APPLICATION,T1WI,T2WI,8/27/2024,86,APPLICATIONT1WIT2WI9/2/202386,SUMMARY,MRI,具有多角度、多层面扫描和多成像参数等特点,能为诊断提供丰富的图像信息,有良好的软组织分辨率，不仅能显示病灶，而且能显示病灶的质地，,动态增强可反映肿瘤的血流动力学,DWI,提供的活体测量技术和磁共振波谱成像可显示肿瘤和正组织间代谢的不同，能在分子水平上反映病理情况,将多种磁共振技术联合使用可以提高乳腺癌诊断的准确率，实现对乳腺癌的超早期诊断，这对提高乳腺癌患者的生存率及生活质量有重要价值,8/27/2024,87,SUMMARYMRI具有多角度、多层面扫描和多成像参数等特点,THANK YOU!,8/27/2024,88,THANK YOU!9/2/202388,