Post on 23-Sep-2020
ESMO PRECEPTORSHIP PROGRAMMEBREAST CANCER
Breast imaging
Name
Kristina Lång
DISCLOSURE OF INTEREST
Disclosure:
• Received speaker’s fee and travel grant from Siemens
Imaging techniques
• Mammography
• Ultrasound
• Tomosynthesis
• MRI
• Contrast enhanced spectral mammography
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• Breast-CT, optical imaging, breast specific gamma imaging, thermography, phase-contrast
mammography…
Diagnosis, staging, and surveillance
Kristina Lång 27 June 2019
MammographyAttenuation
Radio-opaque
Radiolucent
X-ray shadow
• One of the most common X-ray
exams
• Measures the attenuation differences
of tissues with different densities
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Pectoralis
The mammographic gray scale
Fibroglandular tissue
Fat tissue
Calcification
Lymph node
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Kenneth Libbrecht, Reports on Progress in Physics (2005)
The breast is a heterogeneous organ
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The sensitivity of mammography
is affected by:
• Exam technique – compression, positioning, image quality
• Tumour size and growth pattern (inv. lobular cancer)
• Experience of the radiologist (5000/year)
• Breast density (fatty vs fibroglandular and stromal tissue) SensitivityRisk
• Increased risk of breast cancer in extremely dense breasts vs fatty breasts (x5)
Boyd NF et al N Eng J Med (2007)
• Reduced sensitivity in dense breasts due to masking
effect:– Non-dense breasts >70% sensitivity
– Dense breasts <50% sensitivity
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• Mediolateral oblique (MLO)
• Craniocaudal (CC)
• Lateral (ML or LM)
• Additional projections:
- Magnification view
- Projection of the axilla
Standard projections
MLO + CC = screening
MLO + CC + LM = clinical
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Breast compression
• Reduces scattered radiation/secondary radiation – lowers the
radiation dose
• Reduces image noise
• Separates the structures in the breast – improves visualization
• Breast compression can be painful
• Influences the participation rate in screening (25–46% of those
who chooses not to re-attend screening say that compression
pain is the reason)
Whelehan et al. The effect of mammography pain on repeat participation in breast cancer screening: A
systematic review. The Breast (2013)
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One mammogram = 3 months exposure to background radiation
www.iaea.org/Publications/Factsheets Adapted from Baral et al Cancer 1977
Carcinogenic effect of irradiation is
age-dependent
• All symptomatic women >30 y.o.
• Women 25–30 y.o. only with a clinical suspicion of malignancy
• <25 y.o. only with a strong suspicion of malignancy
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Radiation doses of typical medical examinations
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• Soft tissue lesion
• Architectural distortion
• Asymmetri
• Microcalcifications
• Associated findings
Breast cancer appearances on
mammography
The most common
appearance of an
invasive cancer = a
spiculated mass
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IDC FA
• 10–20% have benign
features
• Often fast growing trippel
negative breast cancers
• Medullar och mucinous
cancer
TNBC
Spiculations
Irregular margin
High density
Eccentric localization
Round/oval
Circumbsribed
Smooth margin
Isodense/low density
Halo
Soft tissue mass
Malignant signs Benign signs
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Architectural distortion
Multicentric invasive lobular cancer
Distortion of the breast parenchyma without a visible mass
Manisha Bahl et al. AJR (2015)
• Invasive cancer (often of the lobular type)
• Benign lesions (radial scar, complex
sclerosing adenosis)
• Postoperative distortions
• Architectural distortion without ultrasound
correlate is less likely something malignant
Radial scar
files of cancer cells
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Focal asymmetry
If visible on one
projection: asymmetry
If visible on two
projections: focal
asymmetry
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Microcalcifications
• Typical benign calcifications:
- Punctate or coarse
- Diffuse or isolated group
- Bilateral
• Typical malignant calcifications:
- New
- Thin, pleomorphic
- Linear, branching (ductal pattern)
- Isolated group or segmental
- Unilaterale
Benign
Malignant
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Associated findings
Lymphadenopathy
Unilateal oedema/skin thickening
Skin retraction
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• The whole breast is examined
• Enables comparison with prior examinations
• Sensitive for microcalcifications
• Fast, cheap and accessible
Advantages
Mammography
Disadvantages
• Radiation - not suitable for young women
• Breast compression can be painful
• Limited sensitivity in dense breasts
Summary
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Breast tomosynthesis - an
advancement of the
mammographic technique
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Ultrasonography
Mucinous cancer
Benign cyst
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• High-frequency sound waves are reflected in various
degrees on different types of tissues
• Indications: - Young women (age <30–35)
- Dense breasts
- Characterize/classify lesions seen on
mammography
- Lymph node assessment
- Guidance at interventional procedures
(FNAC, biopsy, preoperative localization,
etc)
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Malignant signs Benign signs
Invasive ductal carcinoma Cyst
”Taller than wide”
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Ultrasonography
Feature analysis
Irregular shape
Indistinct margins
Non-parallell to the skin
Hypo- or heteroechogenic
Through transmission shadow
Non-compressable
Round or oval
Distinct margins
Parallell to the skin
Homogen echogenicity
Through transmission enhancement
Compressable
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IDC IDC
Fibroadenoma TNBC
Jia-wei Li et al. Scientific Reports (2018)
Cancer or not?
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Assessment of lymph nodes
Britton P, Ultrasound of the axilla: where to look for the sentinel lymph node. Clin Radiol (2010)
• 1/3 of patients with normal lymph node
morphology have nodal metastases
• Negative axillary US excludes advanced nodal
disease with a NPV of 96%
Schipper RJ et al, Axillary ultrasound for preoperative nodal staging in breast cancer: is it of added value? Breast (2013)
Seidman H et al, CA Cancer J Clin (1987)
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• Majority of sentinel LN lies in the low axilla
(Level 1)
• Abnormal morphology and cortical thickness
(>4 mm)
• Cytological confirmation
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• New technique (FDA 2009)
• Technicians perform the examination (10–15 min)
• Reproducible; compare with priors
• Additional modality in screening with dense breasts (+2 cancer/1000,
but more FP)
• Positive finding needs further assessment with handheld ultrasound
Andrew Evans et al. Insights into Imaging (2018)
Brigitte Wilczek et al. Eur J Radiol (2016)
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Automated whole breast ultrasound
(ABUS)
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Ultrasonography with elastography
Lee et al. Ultrasonography 2014
• Ultrasound method that measures tissue stiffness
• A significant increase in specificity
• Compression or Shear wave elastography
• Promising method for the evaluation of neoadjuvant
therapy - the tumour stiffness reduces with treatment
WE Berg et al. Radiology (2012)
Andy Evans et al. Ultraschall in Med (2018)
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Ultrasonography
• Cannot visualize the whole breast (NPV
relatively low)
• Microcalcifications
• Operator dependent
• False positives
• No ionizing radiation
• Dense breasts
• Characterize lesions seen on mammography
• Assess lymph nodes
• Guide at interventional procedures
Summary
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Advantages Disadvantages
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Breast MRI (Magnetic Resonance Imaging)
Indications
Peters et al. 2008 Radiology
• Affects and measures the nuclear-magnetic
resonance of water molecules
• Often performed with contrast agent
(gadolinium-based)
• High sensitivity (90%), lower specificity
(72%)
• High risk screening (>20% life time risk)
• Suspicious clinical or mammographic findings that cannot
be solved with conventional methods
• Occult breast cancer (metastases from breast cancer
without breast findings using conventional methods)
• Evaluation of implant integrity
• Evaluation of neoadjuvant therapy
• Preoperative evaluation?
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• Tumour size can be underestimated with mammography and ultrasound, especially invasive lobular carcinoma
• MRI is accurate in estimating tumour extension (multifocality)
• Preoperative MRI is clinical practice in many countries
• A meta-analysis showed that the risk for recurrent disease was not reduced using preoperative MRI, but the risk of
mastectomies increased
• COMICE-trial: RCT evaluating the effect on reoperation rates with and without preoperative MRI. No effect on
reoperation rates (19% vs.19%, OR 0.96)
• MONET-trial: RCT of nonpalpable cancers with and without preoperative MRI. No difference in mastectomy
frequency. Paradoxal higher rate of women with MRI that underwent reoperation (45% vs. 28%)
Preoperative assessment with MRI
Houssami N et al J Clin Oncol (2014)
Houssami N et al Breast Cancer Res Treat. (2017)
R Mann et al. Eur Radiol (2008)
Clauser P, et al. Eur Radiol (2018)
L Turnbull et al. Lancet (2010)
”Breast MRI should not be used routinely for preoperative work-up of
patients with nonpalpable breast cancer.”
N.H.G.M. Peters et al. Eur J Cancer (2010)
Invasive lobular cancer can be considered as an acceptable indication to preoperative MRI
EUSOMA guidelines, Eur J Cancer (2010)
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MRI-sequences
• Before contrast:
- Axial T1W (anatomy, fat-containing lesions, blood, protein-rich
lesions)
- Axial T2W, STIR (water signal)
- Diffusion weighted sequence (DWI, ADC)
• After contrast:
- Dynamic sequences = Axial T1W x 6 (1–7 min)
- Subtraction images (before and after contrast)
- Maximum Intensity Projections (MIP) of subtracted images
T1W
T2W
Dynamic
MIP
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Contrast dynamics
• The dynamic sequences enable assessment of the
contrast enhancement
• Three typical contrast-enhancement patterns:
- Type 1. Slow gradual persistent enhancement (PPV
6%)
- Type 2. Plateu curve with a sharp bend after the
initial upslope (PPV 6–29%)
- Type 3. Early rapid enhancement followed by fast
washout (PPV 29–77%)
Kuhl CK et al. Radiology (1999)
Dhillon GS et al. J Clin Imaging Sci (2011)
An important tool to assess lesions
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Bilateral ca?
56-y.o. woman with a family history of breast
cancer Palpable lump left breast
Bilateral cancer?
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Diffusion weighted imaging
• DWI is sensitive for the motion of water molecules
• In lesions with hight cellularity water have restricted motion
• Can assess lesions without using a contrast agent
IDC
Partridge S et al. J Magn Reson Imaging (2017)
DCIS
Fibroadenoma
Cyst
O'Flynn EA et al. Breast Cancer Res (2011)
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Breast MRI
Advantages Disadvantages
• Sensitive for hormones
• Gadolinium
• Cannot visualize microcalcifications
• False positives
• Expensive, accessibility
• High sensitivity
• Breast density
• No ionizing radiation
• The only method that can visualize the area behind breast
implants
• Multifocality, bilateral cancer
Summary
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Contrast enhanced spectral mammography
(CESM)
• New imaging technique (FDA 2011)
• Iodinated contrast agent
• Dual energy exposure
• High sensitivity, low specificity
• Cost-effective alternative to MRI?
Low energy High energy Recombined
image
Tagliafico et al. Breast (2016)
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Irwig L, Macaskill P. NHMRC National Breast Cancer Centre, 1997
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Triple assessment
1. Medical history and clinical breast examination
2. Imaging – mammography and/or ultrasonography
3. Non-excision biopsy – fine needle aspiration (FNA) cytology and/or core biopsy
Sensitivity close to 100%
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Fine needle aspiration
• Thin needle to aspirate cells for cytology
• Not suitable for cancer diagnosis
https://www.cancer.org/Pijnappel R, Br J Cancer 2004
• Evaluation of lymph nodes
• Evacuate cysts
Needle position
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Core needle biopsy
• Biopsy to obtain tissue for histological diagnosis
• Sensitivity 90%
• Enables assessment of receptor status
• Stereotactic biopsy for microcalcifications
• More traumatic than fine needle aspirations, local
anesthesia
14G, 15–20 mm
Verkooijen HM. Br J Cancer 2000
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S M Bundred et al. BJR (2015)
Vacuum-assisted biopsy
• Needle that can obtain large biopsies with one
insertion
• Expanding collagen plug and a metal-clip is
placed after the biopsy
• High sensitivity
• Indications: sparse microcalcifications, MR-guided
biopsy
11G
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Screening for distans metastasis
• Incidence of metastatic disease in early-stage BC <2%
• Whole body screening (CT) justified: N2 disease, T4 tumour, or local and regional recurrence
• PET-CT for inflammatory cancer
www.rcr.ac.uk
The Royal College of Radiologists. Guidance on screening and symptomatic breast imaging, 3rd ed (2013)
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• Mammography, ultrasonography and core needle biopsies are the
cornerstones of breast imaging
• MRI has high sensitivity and is a valuable tool for various indications (high-risk
screening, problem solver)
• New imaging techniques (tomosynthesis, elastography, CESM) can provide
additional value
Breast imaging Summary
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Thank you for your attention!
kristina.lang@med.lu.se