optimizing RadPath Conference for

residents and medical students

Breast Imaging Division 2018

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R2P2 week 2(Resident RadPath Powerpoint)

R2P2 weekly .pptx aka educational modules

• wk1 basics of radpath-high risk lesions-risk factors amplified

• wk2 basics of radpath amplified-screening mammography-medical audit basics-common cancer histology

• wk3 cancer histologies-breast cancer staging and survival-common benign breast dx

• wk4 molecular subtypes-breast MRI

Today’s R2P2

• Week 2 .pptx to supplement the imaging during discussion

• Amplify Bassett article homework week 1 (follow-up, false negative, underestimation of disease tenets)

• The abnormal screening mammogram

• The medical audit

• Case-based learning histology of breast cancer

Radiology Pathology Concordance

• Concordant (choose one of)

- Clinical follow-up

- 6-month follow-up

- 1-year follow-up

• Discordant (choose one of)

- Re-biopsy same modality

- Re-biopsy different method

- Surgically excise

Radiology Pathology Concordance

• Concordant (choose one of)

- Clinical follow-up: if high risk, malignant, <40 benign

- 6-month follow-up: 14 gauge US CNB

- 1-year follow-up: 9 gauge CNB, FA

• Discordant (choose one of)

- Re-biopsy same modality

- Re-biopsy different method

- Surgically excise

Follow-up for Benign CNB

• Follow-up crucial

• Established schedule and clear recommendations communicated to MD and pt

• ALC 14g (US) benign concordant = 6 month

• VACB 9g (Stereo) benign concordant = 12 month

• 1 year followup adequate for ‘definite benign’ cases 14g (FA)

False negative CNB

• Defined: CNB benign on pathology but with cancer detected on interval followup in same quadrant

• Does not include discordant or underestimation of disease

• False negative rate for CNB 2%

• Equal to excisional biopsy false negative rate

• Follow-up crucial

CNB underestimation of malignancy

• Occurs when CNB of calcs indicates atypia or DCIS but IDC is identified at surgery

• Atypia and DCIS more likely at final pathology if 1-10mm, granular calcs, 8-11 g VACB

• Invasive cancer foci more likely at final pathology if:

a. calcs extended 11 mm or more

b. fine linear branching calcifications

c. 14g ALC device

Bassett LW, Mahoney MC, Apple SK. Interventional Breast Imaging: Current Procedures and Assessing Concordance for Pathology. Radiol Clin N Am 45 (2007) 881–894

Recommend Further Tissue Sampling due to:

• ADH

• ALH and LCIS = lobular neoplasia

• Other high risk lesions per next slides (‘atypia’)

• Radial scar and Complex sclerosing lesion

• Discordance

• Insufficient tissue

• Locally aggressive benign diagnosis per later slide

Today’s R2P2

• Week 2 .pptx to supplement the imaging during discussion

• Amplify Bassett article homework week 1

• The abnormal screening mammogram

• The medical audit

• Case-based learning histology of breast cancer

Remember: At-Risk Population

• Female

• Age > 50

• Mammographically dense breasts

• BRCA1 and BRCA2 - 80% risk

• Syndromes - Li-Fraumeni, Cowden, Peutz- Jeghers, Ataxia Telangiectasis

• Personal history of breast, ovarian, colon cancer

• Personal history of high risk benign biopsy

• Positive family history first degree relative

• Personal history of mantle radiation for Hodgkin Ds

Screening Mammography

• Standard projections MLO and CC

• If Baseline risk pt: Begin age 40 and annual thereafter

• High risk screening pt: test(s) determined by her specific risk parameters ie mammo+US/MR

• SEARCH! Screening mammogram hallmarks of malignancy: suspicious mass, calcifications, site of architectural distortion, asymmetry

Architectural Distortion

• Normal breast architecture is distorted with no definite mass

• Thin straight lines of spiculations radiating from a point; focal retraction, distortion, straightening at the anterior or posterior edge of the parenchyma

• May also be seen in association with asymmetry or calcifications

• Determine if concordant history of trauma or surgery

• DDx = Cancer, Radial scar, Posttraumatic/Surgical scar, Infx

Asymmetries

• Unilateral deposits of fibroglandular tissue not conforming to the definition of a radiodense mass. Four types:

• 1. ASYMMETRY - visible in only one mammographic projection. Typically summation artefact

• 2. GLOBAL ASYMMETRY - large amount of fibroglandular-density tissue over a substantial portion of breast (at least a quadrant) compared to contralateral breast. Usually normal variant

• 3. FOCAL ASYMMETRY - relatively small amount of fibroglandular-density tissue over a confined portion of breast (< a quadrant). Concave borders and interspersed fat distinguish from mass. DDxSuperimposition of two normal structures, Mass

• 4. DEVELOPING ASYMMETRY - focal asymmetry that is new, larger, or more conspicuous than previously. 15% are CA

The Abnormal Screening Mammogram

Abnormal screening mammogram is assigned BI-RADS® CATEGORY 0 and is called back for a Diagnostic breast imaging workup

• For mass/asymmetry: compression magnification views in MLO and CC possibly followed by targeted ultrasound

• For architectural distortion: compression magnification views in MLO and CC possibly followed by targeted ultrasound

• For calcifications: compression magnification views in TL 90 and CC

• PPV1 based on abnormal screening exam 3-8%

• PPV2 when biopsy (surgical, FNA, or core) recommended 20-40%

Case-based learning #3Asymmetry patient

69 yoF abnormal left screening mammogram

LT CC 2016 LT CC 2013

20132016

Case-based learning #3 Asymmetry patient

69 yoF abnormal left screening mammogram

LT CC 2014

Case-based learning #3Asymmetry patient

69 yoF abnormal left screening mammogram

US CNB + Clip Critical to place/confirm clip

Case-based learning #4CA presenting as an asymmetry

69yoF right breast mass

Current RT MLO and CC Prior RT MLO and CC

Case-based learning #4CA presenting as an asymmetry

69yoF right breast mass

Current RT MLO comp mag RT CC comp mag

Screening Mammography

ACR BI-RADS® 5th ed Desirable Medical Audit #s for interpreting radiologists

• Cancer detection rate (per 1000 exams) >2%

• Abnormal interpretation (recall) rate 5-12%

• Sensitivity >75%

• Specificity 88%-95%

• PPV1 based on abnormal screening exam 3-8%

• PPV2 when biopsy (surgical, FNA, or core) recommended 20-40%

ACR BI-RADS® Breast Imaging Audit

ACR BI-RADS® 5th ed now includes auditing procedures for all three modalities Mammography Ultrasound MR• Positive exam defined as further imaging or short interval

surveillance (BI-RADS® 0 and 3) on screening OR tissue diagnosis recommended (BI-RADS® 4 and 5) on diagnostic study

• Negative exam defined as tissue diagnosis not recommended (BI-RADS® 1 and 2 on screening OR BI-RADS® 1, 2 and 3 on diagnostic study)

• True positive TP defined as tissue diagnosis of cancer within 1 year of a positive exam

• True negative TN defined as no tissue diagnosis of cancer within 1 year of a negative exam

• False negative FN defined as tissue diagnosis of cancer within 1 year after the negative exam

• False positive FP has 3 separate definitions (see next slide)

ACR BI-RADS® Breast Imaging Audit

False positive FP has 3 separate definitions:

• FP1 = No known tissue diagnosis of cancer within 1 year of a positive screening examination

• FP2 = No known tissue diagnosis of cancer within 1 year of a tissue diagnosis recommendation

• FP3 = Concordant benign tissue diagnosis or discordant benign tissue diagnosis and no known diagnosis of cancer within 1 year of a tissue diagnosis recommendation

TP + TN + FN + FP = total number of examinations

Today’s R2P2

• Week 2 .pptx to supplement the imaging during discussion

• Amplify Bassett article homework week 1

• The abnormal screening mammogram

• The medical audit

• Case-based learning histology of breast cancer

Ductal carcinoma in situ

• Accounts for 20-25% CA

• Confined to the ducts

• Increased risk in pts with family history, elevated BMI postmenopausal, dense breasts

• Mortality is extremely low and related to IDC 8-10 years post diagnosis of DCIS

• Mammographically detected

• May also present with mass, nipple discharge, Paget’s disease

DCIS on Imaging

• Mammographically detected

• Fine linear and fine linear branching calcifications, pleomorphic calcifications - high grade DCIS

• Amorphous and coarse heterogeneous - low to intermediate grade DCIS

• On MRI - nonmass enhancement with delayed peak enhancement kinetics

• Path DDx UDH, ADH, IDC

Incidence of Histological Types of Invasive Breast Cancer

• Invasive Ductal Carcinoma NST (No special type) 70-80%

• Invasive Lobular Carcinoma 10-15%

Special Type (Rare) Carcinomas each <1-5%• Mucinous• Medullary• Tubular• Papillary • Metaplastic• Anaplastic

Case-based learning #5CA patient

71 yoF right breast mass

MLO CC

Case-based learning #5CA patient

71 yoF right breast mass

MLO CC

Case-based learning #5CA patient

71 yoF right breast mass

MLO CC

Illustrates typical breast imaging care algorithm

• Diagnostic workup to include full field, compression magnification views and ultrasound of mass and axilla

• USCNB + clip for index mass and USCNB (or FNA) of axillary LN

• RadPath review (at UNC, we have RadPathintradepartmental conference)

• Oncologic referral (at UNC, MDC referral and conference discussion)

• Mammographic grid- or US-guided needle localization if breast conservation

• Sentinel node injection unless pt has biopsy proven LN and will undergo axillary node dissection

Infiltrating Ductal Carcinoma NST

• Accounts for 50-75% invasive cancers

• Heterogeneous group of tumors without sufficient histologic features to be classified more specifically

• Ductal origin

• Present as mass, size varies

• Mammogram, US, and MR evident

(Recall pt #4) Infiltrating Lobular Carcinoma

• Accounts for 10% CA• Lobule rather than duct origin• Women in early 60s slightly

older than IDC• Present as thickening• Multifocal, multicentric,

bilateral• Asymmetry, architectural

distortion or occult on mammogram

• Indistinct mass on US• MRI has important role

One final slideCore Foundation RadPath2

DCIS presents as calcs, rarely as Paget, mass.

Accounts for ~25% breast cancer, Stage 0 disease, no

LN spread hence no sentinel node. 100% 5 year survival

Most common invasive cancer is Invasive mammary

of no special type 75%. Special types include ILC 10-

15%, all others <5%

15% developing asymmetries are CA. If subtle asymmetry and architectural distortion, think ILC

Medical Audit desired: Recall rate 5-12%, PPV2 20-40%, Sensitivity

>75% and Specificity 88-95%

One final slideCore Foundation RadPath1

RadPath DIScordancyrequires rebiopsy: often (but not always) needle localization followed by

excision

RadPath CONcordancyrequires followup

recommendation: follow up imaging, clinical

followup, surgical referral

AT RISK Patients include: BRCA gene mutations, other hereditary, prior/family history breast, ovarian colon, prior mantle radiation

HIGH RISK Pathologies include: ADH, FEA, Lobular neoplasia,

Papilloma with atypia, Radial scar CSL

R2P2 weekly .pptx aka educational modules

• wk1 basics of radpath-high risk lesions-risk factors amplified

• wk2 basics of radpath amplified-screening mammography-medical audit basics-common cancer histology

• wk3 cancer histologies-breast cancer staging and survival-common benign breast dx

• wk4 histologies-breast MRI