Updates in Breast Imaging

Updates in Breast Imaging
New Techniques
Continued Controversy
Evita Singh, MD
Department of Radiology
Women’s Imaging
Providence & Providence Park
Breast Density Legislation
Risk based screening
Breast MRI
Tomosynthesis
USPSTF/ACS Recommendations
How things have been…
Screening mammogram at age 40 (or earlier with fam hx)
Patient gets a lay-letter of findings category (BIRADS)
Breast density is reported in physician report (4 categories)
If abnormal screening, get called back for diagnostic workup
with add views+/-ultrasound, and possible biopsy
Radiology pathology concorded in report with
recommendations (benign, high risk atypia, malignant)
Breast Density

The amount of fibroglandular parenchyma in relation to
the amount of fat

Mammogram reports required description
1.
2.
3.
4.
The breast is almost entirely fat
There are scattered fibroglandular densities
The breast tissue is heterogeneously dense. This may lower
the sensitivity of mammography
The breast tissue is extremely dense, which could obscure a
lesion on mammography
4 “Shades of Grey”
Breast Density
Breast cancer and breast parenchyma are both white
Fat is nearly black
The greater amount of fat, the easier it is to recognize a
cancer
Heterogeneously dense and extremely dense breasts can
obscure a cancer, even a large cancer
7
1/21/2016
Cancer in Fatty Breasts
9
1/21/2016
Cancer in Dense Breasts
10
1/21/2016
Breast Density
Cannot be predicted based on physical exam
Unrelated to breast size or consistency
More dense in younger women, during breast feeding,
women using hormone replacement therapy
60% of women under 50, 40% of women in their 50s and
>30% of women in their 60s have radiographically dense
breasts
11
1/21/2016
Why is breast density
important?
Sensitivity and specificity reduced
Sensitivity reduced 33 - 81%
False positives increased
Breast density is a significant independent risk factor for
breast cancer
4-5x relative risk (many considered overestimated)
12
1/21/2016
www.areyoudense.org
ACRIN 6666
Evaluated 2809 women with dense breast, physician
performed US
Mammogram+ US= 29% more cancers detected
53% detection with mamm to 82% combined!
20 % of participants’ cancers were not seen with either
mammography or ultrasound at the time of the initial screen,
but were discovered later during the 12 month period.
Mamm+US yielded 4 times as many false positives as
mammography alone.
Whole Breast Ultrasound
Screening-Why not?
No RCT showing survival benefit in screening dense breasts
with US.
Increased cancer detection but also markedly increased false
positive results.
Not YET recommended by ACR, ACS, NCCN, USPSTF
Dense breasts impacts 50% of women under 50 and 40% of
women over 50= BIG ISSUE!
Low sensitivity for calcifications of DCIS
Breast Density Notification Law
Started by CT in 2009, now 24 states: Conn., Texas, Va.,
N.Y., Calif., Hawaii, Md., Tenn., Ala., Nev., Ore., N.C., Pa,
etc….and MICHIGAN
Law in effect June 1, 2015- SB 0870
Law requires radiologist reporting of increased breast density
to patients via letter with suggestion of additional screening
The letter:
“Your mammogram shows that your breast tissue is dense.
Dense breast tissue is very common and is not abnormal.
However, dense breast tissue can make it harder to find
cancer through a mammogram. Also, dense breast tissue
may increase your risk for breast cancer. This information
about the result of your mammogram is given to you to raise
your awareness. Use this information to discuss with your
health care provider whether other supplemental tests in
addition to your mammogram may be appropriate for you,
based on your individual risk. A report of your results was
sent to your ordering physician. If you are self-referred, a
report of your results was sent to you in addition to this
summary.”
- Michigan Bill 0879 effective 6/1/15
So now what?
Insert patient flow chart
http://www.cancer.gov/bcrisktool/
Risk-Based Screening
Average Risk: <15%
Annual mammogram
Additional advanced screening considered based on density
Intermediate Risk: 15-20%
Personal history of breast cancer or biopsy of atypia
Patient Centered Shared Decision Making Approach
Very High Risk: >20%
First degree relative (mother, sister, daughter) who had
premenopausal breast or ovarian cancer, or a male relative with
breast cancer
BREAST MRI
Breast MRI Screening
Still the only test shown to benefit in detection of cancer in
patients of high risk (>20% based off various models)
Cost has come down: $1500-3000
We are much better: reducing false positive reads and
increased detection of DCIS
“Rapid MRI” in future?
No radiation!
Breast MRI Screening
Paste in the acr screening thing
50yo female, hx of biopsy with
ADH (atypia)
2014
50yo female, hx of biopsy with
ADH (atypia)
2014
Invasive Ductal Carcinoma:
Stage 1
Diagnostic Breast MRI
Preoperative for patients with recently diagnosed breast
cancer
Axillary adenopathy, unknown primary
To help clarify mammogram/ultrasound findings/palpable
abnormality
Nipple discharge
Post op with positive margins
Clinical concern for recurrence, neg mammo/us
45 year old first exam, screening
Preop Breast MRI Metaanalyses
19 studies, 2610 patients with breast cancer
Ipsalateral multicentric breast cancer in 16% of patients
Still controversial regarding impact on survival, delay in surgery,
false positive findings, and increased mastectomy rate
3252 women with unilateral breast cancer
mammographically occult synchronous tumors found in
contralateral breast in 4% (DCIS in 35.1%)
Study comparing imaging modalities with respect to breast cancer
assessment
Index tumors found at mammography in 90%, US 85% and MR
98%
Tumor size underestimated at mammo 14% and US 18%, no
statistical significance in difference on histo from MRI size
4-21% of patients who undergo preop MR have false positive
findings which necessitate additional biopsy
In 50 studies of 10,811 women with breast cancer,
conversion of lumpectomy to mastectomy in 12.8%: of
which 6.8% were in appropriate
Preoperative Breast MRI:
Utilization
Varied use nationally. No comparative studies.
My own research:
University of Chicago: Every cancer patient
Sloan-Kettering: used sparingly
Henry Ford: Surgeon dependent, but used on almost every invasive cancer over
1 cm.
MGH: Every cancer patient
Mayo: Every cancer patient
Cleveland Clinic: Every cancer patient
Louisville: Surgeon dependent but rad puts in report for any cancer for extent of
disease
UNC: most patients with invasive cancer
Atlanta: Surgeon dependent, put into every invasive cancer report
Lowell, MA Community hospital: every case discussed at tumor board and
decided upon before MRI
acrin
50 year old female, fullness
Bilateral
Invasive ductal
carcinoma
Guidelines for Preoperative
Breast MRI
Dense breasts
Lobular Carcinoma
High Risk of inherited breast cancer
Young patients with dense breasts: not every young patient has dense
breasts!
Large Discrepency in size of mammographic abnormality and
ultrasound
Cases with uncertainty for best management option of mastectomy
versus breast conservation
Concern for pectoralis/chest wall, or less so skin involvement clinically
Tomosynthesis
Tomosynthesis
Mammography is mostly limited by overlapping tissue which
causes 2 problems:
Hides cancers
Overlapping tissue can look like cancer and results in a “false
positive” callback
Instead of 2 images of the breast in standard mammography,
tomosynthesis takes multiple “slices” of the breast over different
angles giving a “3D” assessment of the breast tissue reducing
overlap.
While there is a small increase in radiation dose (1.5-2x), the dose
is still below the accepted U.S. MQSA safety standards and is less
than if a patient gets additional views for callback
Tomosyntheis: Recall rates
7,050 mammography only
6,100 combo 2D+tomo
Combo recall rate=8.4%
2D Recall rate=12%
Recall Reduction=30%
9.5% increase in invasive cancer detection P=.93
Haas et al, Radiology 2013
Accuracy and Recall Rates
6 Centers: 1192 subjects
2 enriched reader studies reported
312 cases 48 cancers and 12 readers
Recorded if recall was necessary or not
312 cases with 51 cancers and 15 different readers (retrained)
Recalls, BI-RADS and POM recorded
ROC analysis 2D Vs. 2D/3D
Rafferty, et al Radiology 2013
Accuracy and Recall rates
Increase Accuracy: 7.2% and 6.8%
Increase Sensitivity for Invasive Ca - 15% and 22%
Increase Sensitivity for DCIS - 3%
Decrease Recall: 6 – 67%
Conclusion: Tomo increases accuracy and decreases recall
Rafferty, et al Radiology 2013
454,850 exams from 13 sites across country
281,187 digital mammo
173,663 mammo +tomo
41% more invasive cancers (4.1/1000 screened vs 2.9/1000)
More cancers overall found (5.4/1000 vs 4.2/1000)
Recall rate: 91/1000 vs 107/1000
No difference in discovery of DCISno overdiagnosis or
overtreatment increase
Small Invasive Cancers
Architectural Distortion
2013
2015
Calcifications
Multicentric Disease
Screening Effects
Tomosynthesis will affect all parameters
True negatives
lower recall rate
False negatives
some cancers look benign- sharply circumscribed, lobulated
True positives
shows mass lesions very well, esp spiculated masses
False positives
will see additional lesions on tomo
Who?
ALL PATIENTS BENEFIT from screening with
tomosynthesis over standard mammography
should strongly be considered to patients in the following categories:
Baseline exam
Dense breasts or fibrocystic breasts
High risk patients (including but not limited to BRCA mutation, first
degree relative with premenopausal breast cancer, >20% lifetime risk with
various models)
Patients with previous biopsy of atypia
USPTSF Controversy
The Breast Experts
Risk assessment
Extra imaging in dense breasts
MRI
Tomosynthesis
Molecular imaging
USPTSF
Screening isn’t so great, scares
women, treatments are better
now so they’ll live
Lets screen 50-74 every 2 years
and with mammograms only
USPSTF
No breast surgeons, oncologists, radiation oncologists, or
radiologists on panel!!
Lots of flaws with data including:
Technical parameters of quality of mammography poorly
consistent
“overdiagnosis” was extrapolated data and overestimates
psychological stresses as reasons to not screen
False-positive screening, recall, and false-positive biopsy rate
overestimated based on higher values in younger ages
Radiation dose were based off phantom results which are 26%
higher than in actual patient and incorrectly combined the mean
glandular dose to the right and left breast, doubling the dose
estimate
Etc. etc.
40-84 annual screening
39.6% mortality reduction screening annual 40-84 yo
71% more lives saved as compared to USPSTF recommendations
99,829 lives saved if all women comply: 10,000 per year
64,889 with current 65% compliance rate: 6,500 per year
Effects of Ionizing Radiation report, the risk of fatal radiation induced
breast cancer for woman 40-49 1/100,000 for digital exam and
1.3/100,000 in screen-film, significantly decreased in older women
Read More: http://www.ajronline.org/doi/full/10.2214/AJR.10.5609
Percentage mortality reduction
by various screening stages
The real world
53 year old, no prior, palp
Invasive ductal
51 year old, first mammo in 2013 at age 49,
skipped a year, now 2015
43 year old “palpable lump for
65 days”
First exam ever
Invasive ductal with multicentric dcis
68 year old, first exam