esmo preceptorship programme breast cancer · breast compression • reduces scattered...

ESMO PRECEPTORSHIP PROGRAMMEBREAST CANCER

Breast imaging

Name

Kristina Lång

DISCLOSURE OF INTEREST

Disclosure:

• Received speaker’s fee and travel grant from Siemens

Imaging techniques

• Mammography

• Ultrasound

• Tomosynthesis

• MRI

• Contrast enhanced spectral mammography

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• Breast-CT, optical imaging, breast specific gamma imaging, thermography, phase-contrast

mammography…

Diagnosis, staging, and surveillance

Kristina Lång 27 June 2019

MammographyAttenuation

Radio-opaque

Radiolucent

X-ray shadow

• One of the most common X-ray

exams

• Measures the attenuation differences

of tissues with different densities

4Kristina Lång 27 June 2019

Pectoralis

The mammographic gray scale

Fibroglandular tissue

Fat tissue

Calcification

Lymph node

Kristina Lång ESMO 9 Nov 2018Kristina Lång 27 June 2019

Kenneth Libbrecht, Reports on Progress in Physics (2005)

The breast is a heterogeneous organ

6Kristina Lång ESMO 9 Nov 2018Kristina Lång 27 June 2019

The sensitivity of mammography

is affected by:

• Exam technique – compression, positioning, image quality

• Tumour size and growth pattern (inv. lobular cancer)

• Experience of the radiologist (5000/year)

• Breast density (fatty vs fibroglandular and stromal tissue) SensitivityRisk

• Increased risk of breast cancer in extremely dense breasts vs fatty breasts (x5)

Boyd NF et al N Eng J Med (2007)

• Reduced sensitivity in dense breasts due to masking

effect:– Non-dense breasts >70% sensitivity

– Dense breasts <50% sensitivity


• Mediolateral oblique (MLO)

• Craniocaudal (CC)

• Lateral (ML or LM)

• Additional projections:

- Magnification view

- Projection of the axilla

Standard projections

MLO + CC = screening

MLO + CC + LM = clinical


Breast compression

• Reduces scattered radiation/secondary radiation – lowers the

radiation dose

• Reduces image noise

• Separates the structures in the breast – improves visualization

• Breast compression can be painful

• Influences the participation rate in screening (25–46% of those

who chooses not to re-attend screening say that compression

pain is the reason)

Whelehan et al. The effect of mammography pain on repeat participation in breast cancer screening: A

systematic review. The Breast (2013)


One mammogram = 3 months exposure to background radiation

www.iaea.org/Publications/Factsheets Adapted from Baral et al Cancer 1977

Carcinogenic effect of irradiation is

age-dependent

• All symptomatic women >30 y.o.

• Women 25–30 y.o. only with a clinical suspicion of malignancy

• <25 y.o. only with a strong suspicion of malignancy

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Radiation doses of typical medical examinations


• Soft tissue lesion

• Architectural distortion

• Asymmetri

• Microcalcifications

• Associated findings

Breast cancer appearances on

mammography

The most common

appearance of an

invasive cancer = a

spiculated mass


IDC FA

• 10–20% have benign

features

• Often fast growing trippel

negative breast cancers

• Medullar och mucinous

cancer

TNBC

Spiculations

Irregular margin

High density

Eccentric localization

Round/oval

Circumbsribed

Smooth margin

Isodense/low density

Halo

Soft tissue mass

Malignant signs Benign signs


Architectural distortion

Multicentric invasive lobular cancer

Distortion of the breast parenchyma without a visible mass

Manisha Bahl et al. AJR (2015)

• Invasive cancer (often of the lobular type)

• Benign lesions (radial scar, complex

sclerosing adenosis)

• Postoperative distortions

• Architectural distortion without ultrasound

correlate is less likely something malignant

Radial scar

files of cancer cells


Focal asymmetry

If visible on one

projection: asymmetry

If visible on two

projections: focal

asymmetry


Microcalcifications

• Typical benign calcifications:

- Punctate or coarse

- Diffuse or isolated group

- Bilateral

• Typical malignant calcifications:

- New

- Thin, pleomorphic

- Linear, branching (ductal pattern)

- Isolated group or segmental

- Unilaterale

Benign

Malignant


Associated findings

Lymphadenopathy

Unilateal oedema/skin thickening

Skin retraction


• The whole breast is examined

• Enables comparison with prior examinations

• Sensitive for microcalcifications

• Fast, cheap and accessible

Advantages

Mammography

Disadvantages

• Radiation - not suitable for young women

• Breast compression can be painful

• Limited sensitivity in dense breasts

Summary

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Breast tomosynthesis - an

advancement of the

mammographic technique

Kristina Lång 27 June 2019

Ultrasonography

Mucinous cancer

Benign cyst

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• High-frequency sound waves are reflected in various

degrees on different types of tissues

• Indications: - Young women (age <30–35)

- Dense breasts

- Characterize/classify lesions seen on

mammography

- Lymph node assessment

- Guidance at interventional procedures

(FNAC, biopsy, preoperative localization,

etc)


Malignant signs Benign signs

Invasive ductal carcinoma Cyst

”Taller than wide”

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Ultrasonography

Feature analysis

Irregular shape

Indistinct margins

Non-parallell to the skin

Hypo- or heteroechogenic

Through transmission shadow

Non-compressable

Round or oval

Distinct margins

Parallell to the skin

Homogen echogenicity

Through transmission enhancement

Compressable


IDC IDC

Fibroadenoma TNBC

Jia-wei Li et al. Scientific Reports (2018)

Cancer or not?


Assessment of lymph nodes

Britton P, Ultrasound of the axilla: where to look for the sentinel lymph node. Clin Radiol (2010)

• 1/3 of patients with normal lymph node

morphology have nodal metastases

• Negative axillary US excludes advanced nodal

disease with a NPV of 96%

Schipper RJ et al, Axillary ultrasound for preoperative nodal staging in breast cancer: is it of added value? Breast (2013)

Seidman H et al, CA Cancer J Clin (1987)

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• Majority of sentinel LN lies in the low axilla

(Level 1)

• Abnormal morphology and cortical thickness

(>4 mm)

• Cytological confirmation


• New technique (FDA 2009)

• Technicians perform the examination (10–15 min)

• Reproducible; compare with priors

• Additional modality in screening with dense breasts (+2 cancer/1000,

but more FP)

• Positive finding needs further assessment with handheld ultrasound

Andrew Evans et al. Insights into Imaging (2018)

Brigitte Wilczek et al. Eur J Radiol (2016)

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Automated whole breast ultrasound

(ABUS)


Ultrasonography with elastography

Lee et al. Ultrasonography 2014

• Ultrasound method that measures tissue stiffness

• A significant increase in specificity

• Compression or Shear wave elastography

• Promising method for the evaluation of neoadjuvant

therapy - the tumour stiffness reduces with treatment

WE Berg et al. Radiology (2012)

Andy Evans et al. Ultraschall in Med (2018)


Ultrasonography

• Cannot visualize the whole breast (NPV

relatively low)

• Microcalcifications

• Operator dependent

• False positives

• No ionizing radiation

• Dense breasts

• Characterize lesions seen on mammography

• Assess lymph nodes

• Guide at interventional procedures

Summary

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Advantages Disadvantages


Breast MRI (Magnetic Resonance Imaging)

Indications

Peters et al. 2008 Radiology

• Affects and measures the nuclear-magnetic

resonance of water molecules

• Often performed with contrast agent

(gadolinium-based)

• High sensitivity (90%), lower specificity

(72%)

• High risk screening (>20% life time risk)

• Suspicious clinical or mammographic findings that cannot

be solved with conventional methods

• Occult breast cancer (metastases from breast cancer

without breast findings using conventional methods)

• Evaluation of implant integrity

• Evaluation of neoadjuvant therapy

• Preoperative evaluation?


• Tumour size can be underestimated with mammography and ultrasound, especially invasive lobular carcinoma

• MRI is accurate in estimating tumour extension (multifocality)

• Preoperative MRI is clinical practice in many countries

• A meta-analysis showed that the risk for recurrent disease was not reduced using preoperative MRI, but the risk of

mastectomies increased

• COMICE-trial: RCT evaluating the effect on reoperation rates with and without preoperative MRI. No effect on

reoperation rates (19% vs.19%, OR 0.96)

• MONET-trial: RCT of nonpalpable cancers with and without preoperative MRI. No difference in mastectomy

frequency. Paradoxal higher rate of women with MRI that underwent reoperation (45% vs. 28%)

Preoperative assessment with MRI

Houssami N et al J Clin Oncol (2014)

Houssami N et al Breast Cancer Res Treat. (2017)

R Mann et al. Eur Radiol (2008)

Clauser P, et al. Eur Radiol (2018)

L Turnbull et al. Lancet (2010)

”Breast MRI should not be used routinely for preoperative work-up of

patients with nonpalpable breast cancer.”

N.H.G.M. Peters et al. Eur J Cancer (2010)

Invasive lobular cancer can be considered as an acceptable indication to preoperative MRI

EUSOMA guidelines, Eur J Cancer (2010)


MRI-sequences

• Before contrast:

- Axial T1W (anatomy, fat-containing lesions, blood, protein-rich

lesions)

- Axial T2W, STIR (water signal)

- Diffusion weighted sequence (DWI, ADC)

• After contrast:

- Dynamic sequences = Axial T1W x 6 (1–7 min)

- Subtraction images (before and after contrast)

- Maximum Intensity Projections (MIP) of subtracted images

T1W

T2W

Dynamic

MIP


Contrast dynamics

• The dynamic sequences enable assessment of the

contrast enhancement

• Three typical contrast-enhancement patterns:

- Type 1. Slow gradual persistent enhancement (PPV

6%)

- Type 2. Plateu curve with a sharp bend after the

initial upslope (PPV 6–29%)

- Type 3. Early rapid enhancement followed by fast

washout (PPV 29–77%)

Kuhl CK et al. Radiology (1999)

Dhillon GS et al. J Clin Imaging Sci (2011)

An important tool to assess lesions


Bilateral ca?

56-y.o. woman with a family history of breast

cancer Palpable lump left breast

Bilateral cancer?


Diffusion weighted imaging

• DWI is sensitive for the motion of water molecules

• In lesions with hight cellularity water have restricted motion

• Can assess lesions without using a contrast agent

IDC

Partridge S et al. J Magn Reson Imaging (2017)

DCIS

Fibroadenoma

Cyst

O'Flynn EA et al. Breast Cancer Res (2011)


Breast MRI

Advantages Disadvantages

• Sensitive for hormones

• Gadolinium

• Cannot visualize microcalcifications

• False positives

• Expensive, accessibility

• High sensitivity

• Breast density

• No ionizing radiation

• The only method that can visualize the area behind breast

implants

• Multifocality, bilateral cancer

Summary


Contrast enhanced spectral mammography

(CESM)

• New imaging technique (FDA 2011)

• Iodinated contrast agent

• Dual energy exposure

• High sensitivity, low specificity

• Cost-effective alternative to MRI?

Low energy High energy Recombined

image

Tagliafico et al. Breast (2016)


Irwig L, Macaskill P. NHMRC National Breast Cancer Centre, 1997

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Triple assessment

1. Medical history and clinical breast examination

2. Imaging – mammography and/or ultrasonography

3. Non-excision biopsy – fine needle aspiration (FNA) cytology and/or core biopsy

Sensitivity close to 100%


Fine needle aspiration

• Thin needle to aspirate cells for cytology

• Not suitable for cancer diagnosis

https://www.cancer.org/Pijnappel R, Br J Cancer 2004

• Evaluation of lymph nodes

• Evacuate cysts

Needle position


Core needle biopsy

• Biopsy to obtain tissue for histological diagnosis

• Sensitivity 90%

• Enables assessment of receptor status

• Stereotactic biopsy for microcalcifications

• More traumatic than fine needle aspirations, local

anesthesia

14G, 15–20 mm

Verkooijen HM. Br J Cancer 2000


S M Bundred et al. BJR (2015)

Vacuum-assisted biopsy

• Needle that can obtain large biopsies with one

insertion

• Expanding collagen plug and a metal-clip is

placed after the biopsy

• High sensitivity

• Indications: sparse microcalcifications, MR-guided

biopsy

11G


Screening for distans metastasis

• Incidence of metastatic disease in early-stage BC <2%

• Whole body screening (CT) justified: N2 disease, T4 tumour, or local and regional recurrence

• PET-CT for inflammatory cancer

www.rcr.ac.uk

The Royal College of Radiologists. Guidance on screening and symptomatic breast imaging, 3rd ed (2013)


http://www.rcr.ac.uk

• Mammography, ultrasonography and core needle biopsies are the

cornerstones of breast imaging

• MRI has high sensitivity and is a valuable tool for various indications (high-risk

screening, problem solver)

• New imaging techniques (tomosynthesis, elastography, CESM) can provide

additional value

Breast imaging Summary


Thank you for your attention!

[email protected]

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