imaging after breast cancer
TRANSCRIPT
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Pamela J DiPiro, MDClinical Director of CT and Breast Imager
Dana-Farber Cancer Institute
Imaging after Breast Cancer
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Conflict of Interest Disclosure
I have no financial relationships with a commercial entity producing healthcare-related products and/or services.
Pamela J. DiPiro, MD
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Breast Imaging
• Mammography• Tomosynthesis (3-D mammo)• Ultrasound• Magnetic Resonance Imaging (MRI)• Molecular Breast Imaging (MBI)
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Mammography
• 2005 (DMIST) Digital Mammography Imaging Screening Trial– digital vs film
• women < 50 yrs• heterogeneous or extremely dense• pre- or perimenopausal
• 2D imaging – 2 MLO, 2 CC– +/- magnification, spot, exaggerated views
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45 yo female 7 yrs after lumpectomy and radiation. Asymptomatic.
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51 yo female 3 yrs post lumpectomy and radiation. Asymptomatic.
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2014 2015 2016
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Mammography• Breast screening workhorse• Overall sensitivity =78%*• Varies with breast density• As high as 87% in fatty breasts**• As low as 30% in dense breasts***
*National Cancer Institute website**Carney PA. Ann Intern Med 2003*** Mandelson MT et al. J Natl Cancer Inst 2000
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A B C D
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Digital Breast Tomosynthesis (DBT)
• (3-D) imaging technology that acquires images of a stationary compressed breast at multiple angles during a short scan.
• Individual images are reconstructed into series of thin high-resolution slices.
• Can reduce or eliminate tissue overlap effect
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From Radiol Clin North Am, Sept 2010
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European Prospective Trials
• Oslo - Norway• STORM - Italy• Malmö – Sweden
• Equal or better accuracy in cancer detection with breast tomosynthesis (DBT) compared to digital mammography (2D)
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Tomosynthesis Breast Screening Study * (Oslo, Norway)
• 25,547 women (50-69 yo), biennial• 2D vs 2D+DBT• Improved cancer detection rate:
– 6.4/1000 (63%) – 2D– 8.3/1000 (82%) – 2D + DBT– 1.9 additional cancers/1000
*Skaane et al RSNA 2014
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STORM trial Screening with Tomo OR standard Mammo
• 7292 women (> 48 yo), biennial• 2D vs 2D+DBT• Improved cancer detection rate:
– 5.3/1000 – 2D– 8.1/1000 – 2D + DBT– 2.8 additional cancers/1000– 34% increased detection
*Ciatto et al 2013, Lancet Oncol 2013
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Tomosynthesis in US
• No large prospective studies• Not systematically evaluated (DMIST)• Driven by lay press• Multiple observational studies• Various roles of DBT
– Screening– Diagnostic – Callbacks (+/- spot compression)
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Friedewald et al. JAMA 2014
• Retrospective analysis of 13 acad and nonacad breast ctrs
• Total >450,000 mammos• 2D vs 2D+DBT• Cancer detection increased by 1.2/1000 • Decreased callbacks by 16/1000 (15%)
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Indications for DBT
• Screening (esp Baseline*)–Decreased recall rate– Increased sensitivity
• Diagnostic workup (if BL or request)• Callbacks (not calcifications-mags)**
*McDonald ES et al AJR 2015**Zuley et al. Radiology 2013, Peppard HR. Radiographics 2015
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2012 2011 2008
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62 yo woman w skin dimpling and palpable mass in right lower mid-inner breast
US(-), MRI bx – radial scar
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Tomosynthesis Limitations
• Longer acquisition time• Longer interpretation time (at least 2x)• Greater need for computer power and storage• Slightly more costly• Higher radiation dose (synthesized image*)• May obscure margins of circumscribed masses• Detecting more radial scars
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Tomosynthesis Benefits
• Decreased recall rate• Improved cancer detection 1/1000-2/1000
– spiculated masses– architectural distortion– small, node(-) invasive cancers
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Ultrasound• Important adjunct to mammography
• Indications:– Evaluate palpable lesion– Characterize mammographic finding– Follow response to neoadjuvant
chemotherapy– Attempt to isolate MRI findings– Biopsy/aspiration guidance
– ? Role for dense breast screening
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32 yo female with palpable lump in left breast
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Simple cyst
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32 yo female noted discomfort and “fullness” at lumpectomy site.
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Seroma = post-operative fluid collection
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42 yo female, 1 yr post lumpectomy and radiation with new palpable lump near scar. Mammogram 2 months earlier was (-).
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Courtesy of Dr. Sughra Raza
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2011 2013 2015
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2 years after treatment, new palpable area of concern
Courtesy of Dr. Sona Chikamarne
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Ultrasound Screening
• Controversial• Non-specific• Operator-dependent• Time-consuming• Poor visualization of calcifications • Utilized in Europe, was less popular in
US, until recently
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Dense Breast Tissue
• Approx 40% of women 40-74 yrs• Category C, D• Confers slightly increased cancer risk• Makes cancers harder to detect via
mammography (masks lesions)*
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A B C D
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Dense Breast Legislation• 1st CT in 2009• 28 states* (discussion of federal legislation)• MA - passed legislation 1/1/2015• Mandates informing patient of their breast
density• Variable approaches by state re: disclosure
and recommendation for supplemental imaging
*7 additional states in process
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Discussions in MA
• No immediate test recommended• MD and patient should discuss risk and
further evaluation• Use some type of model to calculate risk• Awareness of U/S thru popular press
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ACRIN 6666 (ACR Imaging Network)
• Prospective trial, April 2004 – Feb 2006 • 2809 women• at least heterogeneous dense + high risk• 21 sites, mammo + U/S (MD-performed)• MD masked to results of other studies
Conclusions*:• U/S yielded additional 4.2 cancers/1000 • Substantial increase # of false (+)
*JAMA 2008. Berg et al.
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Multiple additional studies
• Different populations, including dense screening
• Increased cancer detection (3-4/1000)• Small, invasive cancers, most node (-)• Low PPV for biopsies
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Screening Whole Breast Ultrasound technical limitations
• Long scanning time (19 min – ACRIN 6666)
• Training• Expertise• MD vs tech scan
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Automated Breast Ultrasound
• 1st FDA approved automated breast u/s (9/18/2012)
• 60-70 sec acquisition; 10-15 min total• 3D U/S images (3 planes)• Intended use:
• dense breasts• neg/benign mammogram• no prior invasive procedures
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Ultrasound Overview• Important adjunct to mammo
– Characterizing lesions (palpable, imaged)– Guidance for biopsies/aspirations– Following response to chemotherapy
• Screening– 3-4/1000 additional cancers– High false (+)– High risk women where MRI is unavailable*– Controversial for women with dense breasts as
only risk factor**Sickles EA. Rad Clin North Am
2010
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Magnetic Resonance Imaging (MRI)
• Evolving role in screening and evaluation of breast cancer
• Variably used• ACR Practice Guidelines based on multiple
studies from different institutions
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ACR Practice Parameters for Performance of Contrast Enhanced Breast MRI
• Screening– High risk– Contralateral breast in newly dx’d malignancy (3.1-5%)*– Breast augmentation
• Extent of disease– IDC/DCIS (multifocality/multicentricity)– Invasion deep to fascia– Post-lumpectomy with (+) margins– Neoadjuvant chemotherapy
• Additional evaluation of clinical/imaging findings– Recurrence of breast cancer– Met cancer of unknown primary (suspect breast)– Lesion characterization– Post-op tissue reconstruction with suspected recurrence
*Liberman AJR 2003, Lehman NEJM 2007
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ACS Guidelines for breast screening with MRI as an adjunct to mammography*
• Based on nonrandomized trials/observational studies, annual screening recommended:
» BRCA mutations (and untested 1st degree relatives)» Patients with lifetime risk > 20-25%
• Based on expert consensus and evidence of lifetime risk, annual screening recommended:
» Li-Fraumeni Sx (and 1st degree relatives)» Cowden and Bannayan-Riley-Ruvalcaba Sx (PTEN gene
mutations)
• Insufficient evidence to recommend for or against annual screening (decide on case by case basis):
» Patients with lifetime risk < 15-20%» h/o LCIS, ALH, ADH» Heterogeneously or extremely dense breasts» Personal h/o breast cancer (including DCIS)
*Saslow D et al. CA Cancer Clin 2007
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MRI screening in high risk patients
• BRCA1 and BRCA2 mutations• Li-Fraumeni and PTEN gene
mutations• Strong family history• Prior mantle irradiation for HD
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High Risk Breast Screening
• Annual mammogram• Annual MRI• Typically, stagger 6 mos apart• Can get same time, annually
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54 yo BRCA1 mutation carrier s/p left lumpectomy and radiation for breast cancer and benign right breast biopsy –
screening MRI
Right Breast
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Ultrasound (-) Pathology: DCIS
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Breast MRI sensitivity for cancer detection
• Range: 71-100% in screening MRI studies*• As supplement to mammography: 80-
100% sensitivity**• Sensitivity is lower for in situ than invasive
cancer
• *Mahoney MC. Magn Reson Imaging Clin N Am 2013• ** Warner E. Ann Intern Med 2008
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MRI
• Increased sensitivity• Variable specificity• However- IS used to screen in high
risk populations
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Molecular Breast Imaging (MBI)
• 99mTc-sestamibi mammoscintigraphy • MBI, though less widespread, has been
used for years at sev’l centers• New, dual-head gamma imaging camera
with reported increased sensitivity/specificity and lower dose when compared with earlier systems (sens/spec 96.4% 59.5%)*
• Potential adjunct breast screening modality
*Radiology 2008. Brem et al
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Combined MBI and FFDM1585 women, dense breasts
2D vs 2D + MBI• Yield/1000: 2D 3.2, 2D + MBI 12.0• Sensitivity: 2D 24%, 2D + MBI 91%• Specificity: 2D 89%, 2D + MBI 83%• PPV3: 2D 25%, 2D + MBI 28%
Conclusion:Addition of MBI to screening mammo yielded supplemental
cancer detection rate of 8.8/1000 AJR 2015, Rhodes et al
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Courtesy of Robin Shermis,MD, ProMedica Toledo Hospital, Toledo, OH
63 year old woman with prior history of breast cancer
Mam
mog
ram
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MBI
Advantages: Inexpensive Accessible: Tc99m-sestamibi
Improved sens/equiv spec
Disadvantages: No biopsy device yet Effective dose equivalent of 2.7 mSv to whole body
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Screening• Mammography- imperfect, but remains
screening tool for gen’l population• Tomosynthesis- slight increase in detection,
though increased time +/- radiation• Ultrasound- excellent adjunct, but false (+)
quite high for screening• MRI- screening high risk patients (where cost
and false + acceptable) • MBI- potential adjunct screening in dense
breasts (decrease radiation)