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Imaging After Breast Cancer
This document discusses various breast imaging modalities for screening and diagnosis of breast cancer. It provides an overview of mammography, digital breast tomosynthesis, ultrasound, MRI, and molecular breast imaging. Mammography remains the primary screening tool, though its sensitivity decreases with breast density. Digital breast tomosynthesis has been shown to improve cancer detection rates compared to digital mammography alone. Ultrasound is useful as an adjunct but has high false positive rates for screening. MRI is recommended for screening high risk patients due to its high sensitivity. Molecular breast imaging is a potential adjunct screening tool for dense breasts that may help increase cancer detection over mammography alone.
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Imaging After Breast Cancer
- 1. Pamela J DiPiro,MD Clinical Director of CT and Breast Imager Dana-Farber Cancer Institute Imaging after Breast Cancer
- 2. Conflict of InterestDisclosure I have no financial relationships with a commercial entity producing healthcare-related products and/or services. Pamela J. DiPiro, MD
- 3. Breast Imaging • Mammography •Tomosynthesis (3-D mammo) • Ultrasound • Magnetic Resonance Imaging (MRI) • Molecular Breast Imaging (MBI)
- 4. 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
- 5. 45 yo female7 yrs after lumpectomy and radiation. Asymptomatic.
- 6. 51 yo female3 yrs post lumpectomy and radiation. Asymptomatic.
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- 8. Mammography • Breast screeningworkhorse • 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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- 10. 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
- 11. From Radiol ClinNorth Am, Sept 2010
- 13. 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)
- 14. 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
- 15. STORM trial Screening withTomo 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
- 16. 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)
- 17. 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%)
- 18. 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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- 23. 62 yo womanw skin dimpling and palpable mass in right lower mid-inner breast US(-), MRI bx – radial scar
- 24. Tomosynthesis Limitations • Longeracquisition 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
- 25. Tomosynthesis Benefits • Decreasedrecall rate • Improved cancer detection 1/1000-2/1000 – spiculated masses – architectural distortion – small, node(-) invasive cancers
- 26. Ultrasound • Important adjunctto 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
- 27. 32 yo femalewith palpable lump in left breast
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- 30. 32 yo femalenoted discomfort and “fullness” at lumpectomy site.
- 31. Seroma = post-operativefluid collection
- 32. 42 yo female,1 yr post lumpectomy and radiation with new palpable lump near scar. Mammogram 2 months earlier was (-).
- 33. Courtesy of Dr.Sughra Raza
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- 35. 2 years aftertreatment, new palpable area of concern Courtesy of Dr. Sona Chikamarne
- 36. Ultrasound Screening • Controversial •Non-specific • Operator-dependent • Time-consuming • Poor visualization of calcifications • Utilized in Europe, was less popular in US, until recently
- 37. 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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- 39. 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
- 40. 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
- 41. ACRIN 6666 (ACRImaging 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.
- 42. Multiple additional studies •Different populations, including dense screening • Increased cancer detection (3-4/1000) • Small, invasive cancers, most node (-) • Low PPV for biopsies
- 43. Screening Whole Breast Ultrasoundtechnical limitations • Long scanning time (19 min – ACRIN 6666) • Training • Expertise • MD vs tech scan
- 44. 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
- 46. Ultrasound Overview • Importantadjunct 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
- 47. 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
- 48. ACR Practice Parametersfor 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
- 49. ACS Guidelines forbreast 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
- 50. MRI screening inhigh risk patients • BRCA1 and BRCA2 mutations • Li-Fraumeni and PTEN gene mutations • Strong family history • Prior mantle irradiation for HD
- 51. High Risk BreastScreening • Annual mammogram • Annual MRI • Typically, stagger 6 mos apart • Can get same time, annually
- 52. 54 yo BRCA1mutation carrier s/p left lumpectomy and radiation for breast cancer and benign right breast biopsy – screening MRI Right Breast
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- 54. Breast MRI sensitivityfor 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
- 55. MRI • Increased sensitivity •Variable specificity • However- IS used to screen in high risk populations
- 56. 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
- 57. Combined MBI andFFDM 1585 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
- 58. Courtesy of RobinShermis,MD, ProMedica Toledo Hospital, Toledo, OH 63 year old woman with prior history of breast cancer Mammogram
- 60. MBI Advantages: Inexpensive Accessible: Tc99m-sestamibi Improvedsens/equiv spec Disadvantages: No biopsy device yet Effective dose equivalent of 2.7 mSv to whole body
- 61. 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)