Objectives. What s New in Breast Imaging. Disclosure
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1 Objectives What s New in Breast Imaging Jennifer A. Harvey, M.D., FACR Professor of Radiology University of Virginia Be familiar with new breast imaging technologies including tomosynthesis, screening US, fast MRI, and contrastenhanced spectral mammography (CESM). Describe the potential added benefit and potential negative aspects of screening women with these new modalities Understand how screening may be stratified based on risk and density Disclosure Hologic, Inc. Shareholder and research agreement. Volpara Solutions, Ltd. Shareholder and research agreement. Breast Cancer mortality has declined by >30% since 1990
2 Mammography States with Density Legislation Limitations Many false positives; recall rates 2-15% Mortality reduced by 15-40% (film-screen) Sensitivity reduced in women with dense breasts Potential Improvements Improve visualization of breast structures Functional imaging of blood flow or cellular activity New & Evolving Technologies Tomosynthesis (3D mammography) Screening US Fast MRI Contrast-enhanced spectral mammography
3 New & Evolving Technologies Tomosynthesis (3D mammography) Screening US Fast MRI Contrast-enhanced spectral mammography Breast Tomosynthesis Acquisition X-ray source Compression paddle X-ray tube moves through a proscribed arc of excursion 15 low-dose projection images are acquired during a 5- second sweep Detector Digital Breast Tomosynthesis X-ray tube swings during tomo Recall reduction of 16-40% Reduce Recalls Stationary breast platform Gur D. AJR, Poplack SP. AJR, Rafferty EA. Radiology, 2013.
4 Screening Cancers are More Apparent on Tomo Tomosynthesis Increased Sensitivity with Tomo Norwegian Breast Screening Program 12,631 exams, Nov 2010-Dec 2011 Cancer detection 6.1/1000 mammography alone 8.0/1000 mammo + tomo 30% increase in cancer detection 40% increase in detection of invasive cancers Skaane P. Radiology 2013
5 Screening Screening Recall Screening
6 Primary Advantages of Tomo Reduce summation artifact resulting in improved specificity Improve visualization of cancers, resulting in improved sensitivity and cancer detection rate Reducing Radiation with Tomo 2D + 3D is double radiation dose Dose reduced to similar level using synthesized 2D view No difference in cancer detection or recall rates ADD C VIEW IMAGE Skaane, Radiology 2014 Zuley, Radiology 2014 Challenges with Tomo Higher radiation Increased interpretation time Reimbursement Not likely great for extremely dense tissue New & Evolving Technologies Tomosynthesis (3D mammography) Screening US Fast MRI Contrast-enhanced spectral mammography
7 Bilateral whole breast US Radiologist or technologist performed Automated US commercially available Screening US Connecticut was first with Breast Density Legislation Screening US in High Risk Women ACRIN 6666/Avon trial 2662 moderate and high-risk women had annual mammo + screening US, over 3 years 111 cancers (110 women) Additional cancers by US 5.3 CA/1000 Year CA/1000 Y 2 & 3 8.9% PPV for US lesions Additional 14.7 CA/1000 by MR Berg WA. JAMA 2008 Berg WA. JAMA 2012 Screening US in Practice Studies from practices in CT Additional 3 cancers/ % will have a biopsy PPV for biopsy % 9-20% BI-RADS 3 Weigert J. Breast J 2012 Hooley RJ, Radiology 2012
8 New & Evolving Technologies Fast MRI Tomosynthesis (3D mammography) Screening US Fast MRI Contrast-enhanced spectral mammography Contrast Enhanced One Pre T1, w fat sat Two post contrast, w fat sat Non-contrast T1, no fat sat T2 Diffusion-weighted x 4 Current Breast MRI New & Evolving Technologies T1 T2 T1 FS T1 Post X5 Sag T1 Subtraction Diffusion Weighted (DWI) CAD Tomosynthesis (3D mammography) Screening US Fast MRI Contrast-enhanced spectral mammography
9 Contrast-Enhanced Spectral Mammography (CESM) CESM IV iodinated contrast injection Wait 2 minutes Obtain routine mammographic views Low energy exposure (26-30 kvp)- below k edge of iodine (33 kvp) High energy exposure (45-49 kvp) Fallenberg. Eur Radiol, 2014 Woman in her 50s, right nipple retraction Sensitivity/Specificity of CESM 113 women with abnormal screening mammogram underwent CESM 32 cancers Sensitivity Specificity PPV NPV ROC 2D 96.9% ( ) CESM 100% ( ) 42.0% ( ) 87.7% ( ) 39.7% ( ) 76.2% ( ) 97.1% ( ) 100% ( ) ( ) ( ) Lobbes. Europ Radiol 2014
10 40s, palpable mass LUIQ CESM may have Sensitivity and Specificity Similar to MRI 80 women with new breast cancer underwent MG, CESM, MRI Cancer visible in: 66/80 MG 80/80 CESM 77/79 MRI Fallenberg. Eur Radiol, 2014 CESM False Negative MRI Fallenberg. Eur Radiol, 2014
11 Potential Advantages Functional imaging that may be similar in sensitivity and may be more specific as breast MRI Low cost Not limited by dense tissue New & Evolving Technologies Tomosynthesis (3D mammography) Screening US Contrast-enhanced spectral mammography Fast MRI Potential Disadvantages Higher radiation- 80% higher than conventional 2D Reimbursement Allergic reactions to contrast Current Breast Cancer Screening Women Age 40 (50) and older Add Screening MRI if very high risk (>20% lifetime) Jeunkens. Invest Radiol, 2014
12 Conclusions Mammography reduces breast cancer mortality by 15-40%. This is important but leaves room for improvement. Tomosynthesis decreases recall rate and increases cancer detection by 30%. Results may not be equal across density categories. Screening US also increases cancer detection by 30%, but at the cost of low specificity. May be the current best option for ancillary screening of women with extremely dense tissue. MRI is highly sensitive for invasive breast cancer but is very expensive. Fast techniques may be possible for screening at lower cost. Contrast-enhanced spectral mammography (CESM) may have sensitivity similar to MRI at relatively low cost. May be best option for women with extremely dense breasts in the future. Screening Strategy High Risk Not High Risk Any Density Fatty/ Scattered Heterogeneous Extremely Dense Annual Mammogram + MRI Annual Digital or tomosynthesis Tomosynthesis +and/or US Age to initiate/screening interval based on risk? Digital mammogram + US (or CESM)
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