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Breast imaging update
- 1. Breast Imaging Update 2016 Dra. Angela Mendez
- 2. Objective • Breast imaging recommendation 2014 • Review breast imaging tools • Recommendation depending on risk factors• Recommendation depending on risk factors
- 5. • Breast Cancer • Excluding cancers of the skin, breast cancer is the most common cancer among women, accounting for nearly one out of every three cancers diagnosed in American women.
- 8. ASYMMETRY IS OUR GOAL STANDARD
- 9. AGE AND PROBABILITY T0 DEVELOPED BREAST CANCER IF CURRENT AGEIS THE PROBABILITY OF DEVELOPING BREAST CANCER IN 10 YEARS IS OR 1 IN 20 0.06 % 1,760 30 0.44% 229 40 1.44% 69 50 2.39% 42 60 3.O4% 29 70 3.73% 27 LIFE TIME RISK 12.O8% 8
- 11. When to Start and Stop Screening Breast Cancer Screening Women @ 40 with Bilateral mammography ACR- American College of Radiology ACS -American Cancer Society SBI -Society of breast imagingSBI -Society of breast imaging ACOG- American College of Obstetric and Gynecology ACS- American College of surgeon Sweden improving mortality by 30% in women 40 Impact seen after 10 years of screening
- 12. AVERAGE RISK: Annual mammogram start @ age 40 INTERMEDIATE RISK: Annual mammogram and +/-MRI >15-20% lifetime risk HIGH RISK: Annual mammogram and MRI >20% lifetime risk (BRCA 1,2 Screening Guidelines for American College of Radiology and Society of Breast Imaging HIGH RISK: Annual mammogram and MRI >20% lifetime risk (BRCA 1,2 mutation carrier, 1st degree relative) History of chest irradiation between ages 10-30 Personal Hx of CA (DCIS or Invasive), Ovarian CA or ALH, ADH Dense breast tissue: Annual mammogram +/- Ultrasound state laws current or pending CT , TX, NH, CA, FL, NY
- 13. Risk Assessment Stratification Tools • Gail model uses Current age, race, age at menarche, age at first live birth, the number of first- degree relatives with breast cancer, the number of previous breast biopsy examinations, and presence of atypical hyperplasia. The model predicts a woman's likelihood of having a breast cancer diagnosis within the next 5 years and within her lifetime (up to the age of 90 • Claus model• Claus model Estimates the probability that a woman will develop breast cancer based on her family history of cancer; it incorporates more extensive family history but excludes other risk factors.6 Risk tables have been published by Claus et al and the risks can be calculated as lifetime probabilities of developing cancer or an estimated risk that a woman will develop cancer over 10-year • Tyrer-Cuzick model Accounts for maternal and paternal lineage.
- 14. RED FLAG for Breast Cancer Strong Family history of breast cancer: Two or more first-degree (parent, sibling, or child) or second-degree (grandmother, granddaughter, aunt, niece, half-sibling) relatives with breast or ovarian cancer. Breast cancer occurring before the age of 50Breast cancer occurring before the age of 50 (premenopausal) in a close relative. Family history of both breast and ovarian cancer. One or more relatives with 2 cancers (breast and ovarian cancer or 2 independent breast cancers). Male relatives with breast cancer.
- 15. REDFLAG for breast cancer • Two breast cancer susceptibility gene. • Only 1% to 2% of breast cancer cases are caused by the inheritance of an autosomal dominant. BRCA1 and BRCA2, have recently been identified; these genes are responsible for approximately 40% of cases of inheritedare responsible for approximately 40% of cases of inherited breast cancer. BRCA1 mutations, the average cumulative risk of developing cancer by the age of 70 ranges between 55% and 85% for breast cancer and between 16% and 60% for ovarian cancer. BRCA 2-mutation carriers, the risks range between 37% and 85% for breast cancer and between 11% and 27% for ovarian cancer.
- 16. Breast Cancer Risk according to breast Density Premenopausal and Post menopausal 25 TO 75% RELATIVE RISK 3.4X 75 TO 100% RELATIVE RISK 5.3 X 0 TO 25% RELATIVE RISK 1X
- 17. Why breast density important? • Impacts breast cancer detection Breast cancer sensitivity decreases with breast density • 62% in dense breast • 88% in fatty breast• 88% in fatty breast • Is an independent risk factor for breast cancer Increased in risk 4.6-fold • Mammography cannot differentiate fibrous tissue from glandular tissue.
- 18. IMAGING TOOLS FOR EVALUATION Digital mammography “GOLD STANDARD” for screening Breast ultrasound
- 19. Imaging Tools for Evaluation Breast MRI Digital Breast Tomosynthesis
- 20. Ultrasound of breast • Good with dense breast and palpable finding occult in mammography. • Screening in• Screening in patients with dense breast. • For interventional procedures. • Follow up in patients with dense breast and severe FCC.
- 21. 59 Y/O FEMALE PATIENT PALPABLE ABNORMALITY RIGHT BREAST UOQ
- 24. Breast MRI Powerful Diagnostic Tool • Its role in breast imaging is steadily expanding. • Today its use isindicated in five clinicalsituations: 1. Screening high-risk women. 2. Evaluating indeterminate cases, especially2. Evaluating indeterminate cases, especially with dense or small breasted women. 3. Preoperative staging. 4. Evaluating response to treatment, especially to allow for lumpectomy rather than mastectomy. 5. Screening and evaluation of women with cancer symptoms and breast implants.
- 25. Breast MRI’s Role in Cancer Screening • Breast MRI has unquestionable value in screening women at high risk for breast cancer. • In several studies, the sensitivity of breast MRI for invasive cancer actually has approached 89 TO 96%, proving to be a dramatically more effective tool than mammography for screening thistool than mammography for screening this population. • In high-risk women ,mammography has a sensitivity of only 20% for ductal carcinoma in situ (DCIS) and 26% for invasive cancer, compared to MRI’s sensitivity of 87% for DCIS and 90% for invasive cancer.
- 26. • "It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change." - Charles Darwin- Charles Darwin
- 27. GOLD STANDARD Annual mammography screening reduces breast cancer mortality ~30% • FALSE NEGATIVES: Mammography may miss 20- 30% of breast cancers Risk of breast cancer increased as density increases .Risk of breast cancer increased as density increases . Sensitivity decreases as breast density increases. • FALSE POSITIVES: Mammography Screening Recall Rate ~10% 1/3 of these go to biopsy & 20% of these are Cancer.
- 29. • Breast tomosynthesis is a new tool that can be expected to ameliorate this problem by reducing or eliminating tissue overlap. • Breast tomosynthesis technology is essentially a modification of a digital mammography unit New Tool in Early Screening a modification of a digital mammography unit to enable the acquisition of a three- dimensional (3D) volume of thin-section data. • Images are reconstructed in conventional orientations by using reconstruction algorithms similar to those used in computed tomography (CT).
- 30. X Ray –vs- CT Scan
- 31. Tomosynthesis ReconstructionTomosynthesis Reconstruction • Image slices are reconstructed every 1 mm • Each image contains anatomical information equivalent to about 3 mm of tissuetissue • Anatomical information above and below the 3 mm volume is removed (blurred out) • Image slices contain high resolution information - like conventional mammograms
- 33. TomosynthesisTomosynthesis AcquisitionAcquisition • X-ray tube moves in an arc across the breast • Series of low dose images are acquired at different angles • Projection images are reconstructed into 1mm slices Digital detector Compression plate BreastReconstructed planes
- 34. Figure 2a. Photographs of the experimental breast tomosynthesis unit at the authors’ institution show the x-ray tube positioned at angles of −7.5°°°° (a) and +7.5°°°° (b), the angular range used during image data acquisition. Park J M et al. Radiographics 2007;27:S231-S240 ©2007 by Radiological Society of North America
- 35. Figure 2b. Photographs of the experimental breast tomosynthesis unit at the authors’ institution show the x-ray tube positioned at angles of −7.5°°°° (a) and +7.5°°°° (b), the angular range used during image data acquisition. Park J M et al. Radiographics 2007;27:S231-S240 ©2007 by Radiological Society of North America
- 36. Center Requisites • Pacs (Picture archiving and communication system) electronic archiving system. • Work station. • Radiology interpreter has to be proficient. Be a certfied radilogy by ACR to interpret mammography Evaluate 100 cases under supervision. 8 hours of CME
- 37. 49 y/o female with palpable abnormality RT breast Send for Fine Needle Aspiration
- 41. PALPABLE AREA OBLIQUE VIEWPALPABLE AREA OBLIQUE VIEW
- 50. 36 y/o female spiculated mass & microcalcifications Lt. breast Send for ultrasound guided biopsy & Stereotactic biopsy
- 54. SPICULATED MASS & AXILLARY NODULE OBLIQUE VIEWSPICULATED MASS & AXILLARY NODULE OBLIQUE VIEW
- 58. 29 y/o female asymmetry & nodular structure Lt. breast Send for Tomosynthesis
- 63. 55 y/o female HIGH RISK MOTHER WITH BREAST CANCER AT 60 y/o Send for Tomosynthesis.
- 68. 64 y/o female distortion of the breast architecture reductionarchitecture reduction mammoplasty x2
- 80. 60 y/o female with palpable abnormality at Lt Breast Hx of bilateral lumpectomylumpectomy Sent for ultrasound guided biopsy
- 90. MRI 2011
- 91. MRI 2011
- 93. 69 y/o female patient with Hx of Left Breast Lumpectomy
- 97. / SCREENING @ 40