Breast Imaging Update

2016Dra. Angela Mendez

Objective

• Breast imaging recommendation 2014

• Review breast imaging tools

• Recommendation depending on risk factors • Recommendation depending on risk factors

• Breast Cancer

• Excluding cancers of the skin, breast cancer is

the most common cancer among women,

accounting for nearly one out of every three

cancers diagnosed in American women.

ASYMMETRY IS OUR GOAL STANDARD

AGE AND PROBABILITY T0

DEVELOPED BREAST CANCERIF CURRENT

AGEIS

THE PROBABILITY OF DEVELOPING

BREAST CANCER IN 10 YEARS IS

OR 1 IN

20 0.06 % 1,760

30 0.44% 229

40 1.44% 69

50 2.39% 42

60 3.O4% 29

70 3.73% 27

LIFE TIME RISK 12.O8% 8

When to Start and Stop Screening

Breast Cancer Screening Women @ 40 with Bilateral mammography

ACR- American College of Radiology

ACS -American Cancer Society

SBI -Society of breast imagingSBI -Society of breast imaging

ACOG- American College of Obstetric and Gynecology

ACS- American College of surgeon

Sweden improving mortality by 30% in women 40

Impact seen after 10 years of screening

AVERAGE RISK: Annual mammogram start @ age 40

INTERMEDIATE RISK: Annual mammogram and +/-MRI >15-20% lifetime risk

HIGH RISK: Annual mammogram and MRI >20% lifetime risk (BRCA 1,2

Screening Guidelines for American

College of Radiology and Society of

Breast Imaging

HIGH RISK: Annual mammogram and MRI >20% lifetime risk (BRCA 1,2

mutation carrier, 1st degree relative)

History of chest irradiation between ages 10-30 Personal Hx of CA (DCIS or

Invasive), Ovarian CA or ALH, ADH

Dense breast tissue: Annual mammogram +/- Ultrasound

state laws current or pending CT , TX, NH, CA, FL, NY

Risk Assessment Stratification Tools

• Gail model uses

� Current age, race, age at menarche, age at first live birth, the number of first-degree relatives with breast cancer, the number of previous breast biopsy examinations, and presence of atypical hyperplasia. The model predicts a woman's likelihood of having a breast cancer diagnosis within the next 5 years and within her lifetime (up to the age of 90

• Claus model • Claus model

� Estimates the probability that a woman will develop breast cancer based on her family history of cancer; it incorporates more extensive family history but excludes other risk factors.6 Risk tables have been published by Claus et al and the risks can be calculated as lifetime probabilities of developing cancer or an estimated risk that a woman will develop cancer over 10-year

• Tyrer-Cuzick model

� Accounts for maternal and paternal lineage.

RED FLAG for Breast Cancer

Strong Family history of breast cancer:

�Two or more first-degree (parent, sibling, or child) or

second-degree (grandmother, granddaughter, aunt,

niece, half-sibling) relatives with breast or ovarian

cancer.

�Breast cancer occurring before the age of 50 �Breast cancer occurring before the age of 50

(premenopausal) in a close relative.

�Family history of both breast and ovarian cancer.

�One or more relatives with 2 cancers (breast and ovarian

cancer or 2 independent breast cancers).

�Male relatives with breast cancer.

REDFLAG for breast cancer

• Two breast cancer susceptibility gene.

• Only 1% to 2% of breast cancer cases are caused by the inheritance of an autosomal dominant.

�BRCA1 and BRCA2, have recently been identified; these genes are responsible for approximately 40% of cases of inherited are responsible for approximately 40% of cases of inherited breast cancer.

�BRCA1 mutations, the average cumulative risk of developing cancer by the age of 70 ranges between 55% and 85% for breast cancer and between 16% and 60% for ovarian cancer.

�BRCA 2-mutation carriers, the risks range between 37% and 85% for breast cancer and between 11% and 27% for ovarian cancer.

Breast Cancer Risk according to breast

Density Premenopausal and Post

menopausal

25 TO 75% RELATIVE RISK

3.4X

75 TO 100% RELATIVE RISK

5.3 X

0 TO 25% RELATIVE RISK

1X

Why breast density important?

• Impacts breast cancer detection

�Breast cancer sensitivity decreases with

breast density

• 62% in dense breast

• 88% in fatty breast• 88% in fatty breast

• Is an independent risk factor for breast

cancer

�Increased in risk 4.6-fold

• Mammography cannot differentiate fibrous tissue

from glandular tissue.

IMAGING TOOLS FOR EVALUATION

Digital mammography

“GOLD STANDARD” for

screening

Breast ultrasound

Imaging Tools for Evaluation

Breast MRI Digital Breast Tomosynthesis

Ultrasound of

breast

• Good with dense breast and palpable finding occult in mammography.

• Screening in • Screening in patients with dense breast.

• For interventional procedures.

• Follow up in patients with dense breast and severe FCC.

59 Y/O FEMALE PATIENT PALPABLE ABNORMALITY

RIGHT BREAST UOQ

Breast MRI Powerful Diagnostic Tool

• Its role in breast imaging is steadilyexpanding.

• Today its use isindicated in fiveclinicalsituations:1. Screening high-risk women.

2. Evaluating indeterminate cases, especially2. Evaluating indeterminate cases, especiallywith dense or small breasted women.

3. Preoperative staging.

4. Evaluating response to treatment, especiallyto allow for lumpectomy rather thanmastectomy.

5. Screening and evaluation of women withcancer symptoms and breast implants.

Breast MRI’s Role in Cancer Screening

• Breast MRI has unquestionable value in screening women at high risk for breast cancer.

• In several studies, the sensitivity of breast MRI for invasive cancer actually has approached 89 TO 96%, proving to be a dramatically more effective tool than mammography for screening this tool than mammography for screening this population.

• In high-risk women ,mammography has a sensitivity of only 20% for ductal carcinoma in situ (DCIS) and 26% for invasive cancer, compared to MRI’s sensitivity of 87% for DCIS and 90% for invasive cancer.

• "It is not the strongest of the species that

survive, nor the most intelligent, but the one

most responsive to change."

- Charles Darwin- Charles Darwin

GOLD STANDARD

Annual mammography screening reduces breast cancer mortality

~30%

• FALSE NEGATIVES: Mammography may miss 20- 30% of breast

cancers

Risk of breast cancer increased as density increases .Risk of breast cancer increased as density increases .

Sensitivity decreases as breast density increases.

• FALSE POSITIVES:

Mammography Screening

Recall Rate ~10% 1/3 of these go to biopsy & 20% of these are

Cancer.

Tomosynthesis

• Elizabeth Rafferty

• Breast tomosynthesis is a new tool that can

be expected to ameliorate this problem by

reducing or eliminating tissue overlap.

• Breast tomosynthesis technology is essentially

a modification of a digital mammography unit

New Tool in Early Screening

a modification of a digital mammography unit

to enable the acquisition of a three-

dimensional (3D) volume of thin-section data.

• Images are reconstructed in conventional

orientations by using reconstruction

algorithms similar to those used in computed

tomography (CT).

X Ray –vs- CT Scan

Tomosynthesis ReconstructionTomosynthesis Reconstruction

• Image slices are reconstructed every 1 mm

• Each image contains anatomical information equivalent to about 3 mm of tissuetissue

• Anatomical information above and below the 3 mm volume is removed (blurred out)

• Image slices contain high resolution information - like conventional mammograms

TomosynthesisTomosynthesis ReconstructionReconstruction

TomosynthesisTomosynthesis AcquisitionAcquisition

• X-ray tube moves in an arc across the breast• Series of low dose images are acquired at different angles • Projection images are reconstructed into 1mm slices

Digital detector

Compression plate

BreastReconstructed planes

Figure 2a. Photographs of the experimental breast to mosynthesis unit at the authors’ institution show the x-ray tube positioned at angle s of −7.5°°°° (a) and +7.5°°°° (b), the

angular range used during image data acquisition.

Park J M et al. Radiographics 2007;27:S231-S240

©2007 by Radiological Society of North America

Figure 2b. Photographs of the experimental breast to mosynthesis unit at the authors’ institution show the x-ray tube positioned at angles of −7.5 °°°° (a) and +7.5°°°°

(b), the angular range used during image data acqui sition.

Park J M et al. Radiographics 2007;27:S231-S240

©2007 by Radiological Society of North America

Center Requisites

• Pacs (Picture archiving and communication system) electronic archiving system.

• Work station.

• Radiology interpreter has to be proficient.�Be a certfied radilogy by ACR to interpret mammography

�Evaluate 100 cases under supervision.

�8 hours of CME

49 y/o female with

palpable abnormality

RT breast

Send for Fine Needle Aspiration

PALPABLE AREA OBLIQUE VIEWPALPABLE AREA OBLIQUE VIEW

36 y/o female

spiculated mass &

microcalcifications

Lt. breast

Send for ultrasound guided biopsy &

Stereotactic biopsy

SPICULATED MASS & AXILLARY NODULE OBLIQUE VIEWSPICULATED MASS & AXILLARY NODULE OBLIQUE VIEW

29 y/o female

asymmetry & nodular

structure Lt. breast

Send for Tomosynthesis

55 y/o female HIGH RISK

MOTHER WITH BREAST CANCER

AT 60 y/o

Send for Tomosynthesis.

64 y/o female

distortion of the breast

architecture reduction architecture reduction

mammoplasty x2

60 y/o female with

palpable abnormality at

Lt Breast

Hx of bilateral

lumpectomy lumpectomy

Sent for ultrasound guided

biopsy

BILATERAL MAMMOGRAPHY

2010

SONOMAMMOGRAM 2010

BILATERAL MAMMOGRAPHY

2011

SONOMAMMOGRAM 2011

MRI 2011

MRI 2011

69 y/o female patient

with Hx of Left Breast

Lumpectomy

Mammography 2012Mammography 2012

Tomosynthesis 2012

/ SCREENING @ 40