Jon E. Ekstrom, MD

I have no relevant financial disclosures

Breast Carcinoma 1 in 8 U.S. Women will develop Breast CA In 2015 estimated 231,840 new cases of invasive breast

CA and 60,290 new cases of in situ disease. In 2015, 40,290 Breast CA deaths are expected with

mortality rate decreasing since 1989. In 2015, there are more than 2.8 million women in the

U.S. with current or past history of Breast CA.

Breast CA in Oregon Oregon is ranked the 2nd highest in the nation for

Breast CA incidence (128.6/100,000) WA is # 1. Leading cancer Dx in Women from all racial and

ethnic groups. The % of early stage (localized and in situ) is 74% The mortality rate of Breast CA in OR is lower than the

national average. ? Northwest has high rate of Breast CA screening and

large population of older white women who may have better outcomes than many minorities

Screening Mammography Recent conflict and debate Population based policy vs individualized medicine. In most practices, 10 – 15% of new Breast CA diagnosis

are in women less than age 50. We cannot reliably inform a patient when it is safe to

postpone screening. 1/6 Breast CA deaths attributed to diagnosis in 40’s 1/3 of all years of life lost to Breast CA are from

diagnosis before age 50.

Breast Density and Cancer Risk Increased Breast density is a marker of increased risk

for developing Breast CA. No Increase in Breast CA Mortality. BIRADS Lexicon. No Standardization (subjective) Decreased Detection of Breast Ca. ? Surrogate Marker of cellular proliferation. ?Reflection of endogenous hormone environment. Is past or current breast density most important to

establish risk?

Breast Density

Mammography History Standard X-Ray Mammography (-1930) Xerox Mammography (1970 – 1985) Film / Screen Based Mammography (1980s – 2010) Digital Mammography (2005 – Current) 3D Mammography (Tomography)

Conventional Mammography

Tissue superimposition

Projection imaging

Detector

Breast

Compression Plate

X-rays

Problems Often unclear detection method High amounts of over-diagnosis and under-diagnosis This leads to multiple unnecessary screenings and

more exposure to X-ray radiation Limited 2-dimensional image leaves about 10% of

cancers undetected Denser breast tissue is difficult to read in some

patients

3D Mammography=Tomosynthesis First system approved by FDA – 2011 System acquires multiple images of the Breast through

a moving Beam. Images are reconstructed at 1 mm slices.

2D image is generated from the tomosynthesis data

Tomosynthesis

Utilizes low-level X-rays to produce multiple images of the breast, layer by layer, using a swinging camera

This layering of images makes it simpler to detect normal breast structures (milk ducts, lobules, fatty tissues, etc.) from cancerous ones

X-rays are converted into limited 3-dimensional digital images for radiologists to examine

Computer Aided Detection (CAD) assists in spotting regions where cancer seems to be present

Dense tissue is more easily examined through Tomography than traditional Mammography

Tomosynthesis

Digital Breast Tomosynthesis

Tomographic Imaging

Tube Rotation

Detector

Breast

X-rays

Compression Plate

• Tissue superimposition :• hides pathologies in 2D• mimics pathologies in

2D

Why 3D Mammography/DBT?

16

Why 3D Mammography?

Tomosynthesis: A Better Mammogram ADVANTAGES

Higher Detail Helps Delineate

Overlapping Tissues Increased CA Detection

Rate Decreased Call Back

Rate

DISADVANTAGES Longer Interpretation

Time More Costly (>80 % of

Carriers are Covering) Still Difficulties with

Uniformly very dense Breast Tissue

Tomosynthesis (cont.) Increases detection of Invasive breast cancers by 40%

in comparison to 2D mammography Total cancer detection increased from 6.1 patients per

thousand to 8.0 patients per thousand (a 27% increase)

False-positive readings reduced by 15% Uncertain readings and patient call-backs reduced by

20-30%

Clinical Performance: Overall CA detection Rate increased 27% over Digital

Mammography (Oslo trial – 12,631 screenings in 2 yrs) False Positive Rate Decreased by 15%

Tomosynthesis

2D MammographyA suspicious region

3D Mammography (slice 17)A highly suspicious region

Hologic – Proprietary and Confidential

EXAMPLE

sametissue

Hologic – Proprietary and Confidential

EXAMPLE

sametissue

2D MammographyA worrisome region

3D Mammography (slice 22)A very worrisome region

Reduced Call Backs

Reduced Call Backs

Tomosynthesis 2D images from Tomosynthesis Data (C View) Hologic (2011). Reduce Exposure Time and Dose. Dose is equivalent

to Conventional Digital Mammography.

Tomosynthesis

Example8/10/2015 Digital Mammo 8/20/2015 Tomo Mammo

Ultrasound Findings3:00 Lesion 1:00 Lesion

Tomosynthesis: Additional Advantages More accurate Characterization of Lesion Size

Able to Locate Difficult Lesions in 3 Dimensions

Image Guided Biopsy Systems

Contrast Enhanced Mammography

Guided Biopsy Localize Target in x,y,

and z Planes. More Comfortable than

Prone Stereotactic Table

Contrast Enhanced Tomo

Contrast Enhanced Tomo Patients who are not MRI Candidates

Where MRI is not Available

Reduced Cost over MRI

Still a Work in Progress

Thank You