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Pamela J DiPiro, MD Clinical Director of CT and Breast Imager Dana-Farber Cancer Institute Imaging after Breast Cancer
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Conflict of Interest Disclosure Pamela J. DiPiro, MD I have no financial relationships with a commercial entity producing healthcare-related products and/or services.
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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 FFDM 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
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Courtesy of Robin Shermis,MD, ProMedica Toledo Hospital, Toledo, OH 63 year old woman with prior history of breast cancer Mammo m
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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)