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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