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2 nd annual San Antonio breast cancer symposium review january 28, 2012

2 nd annual San Antonio breast cancer symposium review january 28, 2012. Sponsored By:. THE NEWEST TECHNIQUES FOR BREAST IMAGING. ARE THERE ANY KEEPERS ? MAXINE JOCHELSON MD MSKCC . Breast Imaging Tools Today. Mammography (X-Ray ) Purpose : Primary Screening

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2 nd annual San Antonio breast cancer symposium review january 28, 2012

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  1. 2nd annual San Antonio breast cancer symposium reviewjanuary 28, 2012 Sponsored By:

  2. THE NEWEST TECHNIQUES FOR BREAST IMAGING ARE THERE ANY KEEPERS ? MAXINE JOCHELSON MD MSKCC

  3. Breast Imaging Tools Today Mammography (X-Ray) Purpose: Primary Screening Advantages: inexpensive, widely available ,proven to reduce Mortality Disadvantages: low sensitivity with dense breast tissue, • Ultrasound • Purpose: Evaluation of mammographic findings and masses. biopsy. ?screening • Advantages: no radiation, inexpensive • Disadvantages: time consuming, • operator dependent, sub-optimal detection of DCIS and calcs. Low positive predictive value • Breast MRI • Purpose: screening, determine extent of known cancer, f/u • Advantages: extremely sensitive • no radiation, physiology +anatomy • Disadvantages: expense, lacks specificity, claustrophobia, • no implanted metal, not universally available

  4. EVOLUTION OF STANDARD TECHNOLOGY • DIGITAL BREAST TOMOSYNTHESIS (DBT) • CONTRAST ENHANCED MAMMOGRAPHY (CESM) • ULTRASOUND WITH ELASTOGRAPHY • ULTRASOUND WITH MICROBUBBLES • MRI WITH DIFFUSION WEIGHTED IMAGING • MRI WITH SPECTROSCOPY

  5. NEW PLATFORMS: NUCLEAR IMAGING AND COMPUTERIZED TOMOGRAPHY • IMAGING WITH MIBI (MBI)(BSGI) • POSITRON EMISSION MAMMOGRAPHY (PEM) INCLUDING NEW TRACERS • CT AND PET/CT OF THE BREAST

  6. Digital mammography (FFDM) • Lower radiation dose • Display is different-can manipulate images • Improved performance in dense breasts: sensitivity increased from 55-70%* • No increase in overall detection • Serves as a template for DBT and cedm • Pisano ED NEJM 2005

  7. TOMOSYNTHESIS FDA APPROVED TO BE PERFORMED WITH FFDM

  8. Multiple projections of compressed breast with moveable X-Ray source • Image slices reconstructed in plane parallel to detector • Strips away superimposed tissue • 2x Radiation of FFDM

  9. IMPROVED LESION CONSPICUITYPRIMARILY WITH SOFT TISSUE LESIONS • CHARACTERIZATION OF LESIONS • MARGIN FEATURE ANALYSIS • DETECTION OF ADDITIONAL FINDINGS • MAY SHOW NORMAL PARENCHYMA WHEN A MASS IS SUSPECTED IMPROVED SENSITIVITY AND SPECIFICITY

  10. DECREASED NUMBER OF CALLBACKS • POPLACK: 40% DECREASE 99 WOMEN: AJR 2007 • SMITH: 39% DECREASE: LNCS 2008 • KOPANS: 41% (7.8% TO 4.6%) 3015 SINGLE VIEW TOMO EXAMS WITH 2 VIEW FFDM: RSNA 2009 • THIS IS AN ADVANTAGE IF USED FOR SCREENING W/O FFDM

  11. DBT COMPARED TO SPOT FILMS • 67 MASSES: 30 CANCERS, 37 BENIGN • MASS CHARACTERIZATION EQUIVALENT BETWEEN 2 MODALITIES • DBT SHOWED 7 ADDITONAL CANCERS AND 5 ADDITIONAL FALSE +’S Noroozian et al Radiology Jan 2012

  12. ADDITIONAL RADIATION • DECREASING THE ADDITIONAL VIEWS OBTAINED ON CALL BACKS MAY PARTIALLY NEGATE THE ADDITIONAL RADIATION FROM TOMOSYNTHESIS. (10% CALLBACK RATE) • ALL STILL FALL WITHIN MQSA GUIDELINES

  13. DBT Clinical Examples DBT LMLO Source: Oncological Institute of Veneto, Padua, Italy Caution – Investigational Device Limited by United States Law to Investigational Use

  14. DBT Clinical Examples Images courtesy of Dr. Hak Hee Kim Asan Medical Center, Seoul, Korea Caution – Investigational Device Limited by United States Law to Investigational Use

  15. MICROCALCIFICATIONS • NOT AS EASILY ASSESSED W/DBT DUE TO THIN (1MM) SLICES AND BLURRING OF TOMOGRAPHY • PROBABLY EQUIVALENT TO FFDM:

  16. MICROCALCIFICATIONS • SENSITIVITY HIGHER FOR FFDM 84% VS 75% • SPECIFICITY HIGHER FOR FFDM 71% VS 64% • FFDM DETECTED MORE CANCERS WITH CALCIFICATIONS • DIFFERENCES NOT SIGNIFICANT Spangler et al AJR Feb 2011

  17. MICROCALCIFICATIONS • 103 PATIENTS: FFDM VS DBT • ALL HAD KNOWN SUSPICIOUS CALCS • 95% DBT WAS EQUIVALENT OR BETTER • DBT LESIONS 18MM VS 16MM FFDM • Destounis et al ARRS May 2011

  18. FREE RESPONSE ROC PARADIGM • 125 EXAMS RETROSPECTIVELY EVALUATED • FFDM ALONE OR WITH TOMOSYNTHESIS • COMBINATION SHOWED MORE TRUE + ABNORMALITIES • ALSO MORE FALSE+ BUT THE GOOD OUTWEIGHED THE BAD • 16% PERFORMANCE IMPROVEMENT (ON AVERAGE) • GUR ETAL AJR March 2011

  19. ADDITIONAL ISSUES • EVALUATES ONLY ANATOMY • AMOUNT OF TIME NEEDED FOR INTERPRETATION (ROLE FOR CAD) • LIMITED TO NO REIMBURSEMENT • WHEN TO USE: ALL SCREENS, HIGH RISK OR WORK/UP AFTER SCREEN • ?NEED FOR FFDM

  20. CONCLUSIONS • PROMISING BUT NOT READY FOR CLINICAL ROLE OUT-BUT IT IS ADVERTISED TO THE PUBLIC • THEY ARE BEING PURCHASED ~90-110 UNITS (10,000 MAMMO UNITS) • ONCE 1 PLACE GETS ONE-EVERYONE WANTS ONE

  21. 3-D Mammograms: Ultimate Benefits Unknown. The Boston Globe (8/15, Carmichael) reports on the 3-dimensional mammography machines, which were approved by the Food and Drug Administration in February. The technology is promoted as being more accurate than 2-d, because 3-d is better at imaging formations of breast cancer cells such as "spicules, or thin, spidery tentacles emerging from the center of a tumor" which are a mark of malignancy. However, as the Globe points out, "the most meaningful data" on any changes on morbidity and mortality "won't be available for decades

  22. DUAL ENERGY CONTRAST ENHANCED DIGITAL MAMMOGRAPHY (CEDM) ADDING PHYSIOLOGY TO ANATOMY FDA APPROVED AS CESM 11/2011

  23. BACKGROUND MRI is useful in breast imaging due to its ability to image blood flow Could contrast enhancement using digital mammographic technology approach the usefulness of MRI?

  24. MATERIALS Digital mammography unit adapted to perform low & high energy exposures: “iodine image” IODINATED CONTRAST-SAME AS CT

  25. WHAT ARE THE RISKS? Iodinated contrast administration Radiation: 20% > than screening mammo (equivalent to 1 extra image)

  26. EARLY DATA • 142 LESIONS IN 120 PTS • UNILATERAL MAMMO+CEDM VS MAMMO ALONE • SENSITIVITY 93% VS 78% W/O CHANGE IN SPECIFICITY • DromainEurRadiol 2011

  27. NEXT STEPS CONFIRM FEASIBILITY OF BILATERAL CEDM TO COMPARE CEDM and MRI • For ability to detect breast cancer • To define the extent of tumor • For false positive rates Jochelson et al RSNA 2010

  28. DETECTION OF INDEX LESION CEDM 25/26 = 96% MRI 25/26 = 96% MAMMO 22/26 = 85%

  29. INDEX LESIONS DETECTED BY CEDM Lesion size: range, 5 to 50 mm (MEDIAN 12)

  30. MRI vs CEDM MRI CEDM INDEX CANCER: true + 2525 false - 1 1 ADDITIONAL IPSI CANCER: true + 7 5 false + 4 0 false – 0 2 CONTRALATERAL CANCER: true + 0 0 false + 3 0

  31. MRI vs CEDM MRI CEDM INDEX CANCER: true + 25 25 false - 1 1 ADDITIONAL IPSI CANCER: true + 75 false + 4 0 false – 0 2 CONTRALATERAL CANCER: true + 0 0 false + 3 0

  32. MRI vs CEDM MRI CEDM INDEX CANCER: true + 25 25 false - 1 1 ADDITIONAL IPSI CANCER: true + 7 5 false + 40 false – 0 2 CONTRALATERAL CANCER: true + 0 0 false + 3 0

  33. MRI vs CEDM MRI CEDM INDEX CANCER: true + 25 25 false - 1 1 ADDITIONAL IPSI CANCER: true + 7 5 false + 4 0 false – 0 2 CONTRALATERAL CANCER: true + 0 0 false + 30

  34. CEDM vs MRI sensitivity of lesion detection Of all known sites of cancer in the breasts, those identified by each technology were: CEDM 30/33 = 91% MRI 32/33 = 97%

  35. CEDM VS MRIlesion specificity Of all enhancing lesions, cancers were: CEDM 30/30 = 100% MRI 30/37 = 81%

  36. CONCLUSIONS • CEDM matches MRI in its ability to detect PRIMARY CANCER within THE breast (KNOWING THERE IS A CANCER) • The issue of screening is not addressed • IT DETECTS FEWER LESIONS WITHIN THE BREAST-CLINICAL IMPORTANCE TO BE DETERMINED • CEDM detects malignant disease in the breast with fewer false positives than MRI

  37. CASE FOR ULTRASOUND • For further evaluation of mammo and clinical findings • For core biopsies SCREENING • Low sensitivity of mammo particularly in dense breasts • No radiation • Inexpensive • Widely available

  38. PROBLEM WITH ULTRASOUND • .4% PICK UP OF ADDITIONAL LESIONS • Lots of additional biopsies • 90% OF BIOPSIES ARE BENIGN • LARGE NUMBER OF SHORT INTERVAL FOLLOW-UP EXAMS • Radiologist’s annuity

  39. ULTRASOUND CONTRAST AGENT • Microbubbles of gas within lipid microspheres • Oscillate and emit signals detected by u/s probe • Differ from iodine- do not diffuse outside the vessel • Improves vessel visualization c/w Doppler • Not easy to use

  40. MICROBUBBLES • Early studies show improved sensitivity of up to 100% • Specificities 5.6-100% (increased small –non-relevant-vessel detection • KedarRadiol 1996 • Moon Radiol 2000 • Alamo EurRadiol 2001

  41. CONTRAST-ENHANCED BREAST ULTRASONOGRAPHY (CEUS) • Liu et al: J Ultrasound Med 2009:104 patients with breast masses: CEUS correlated with histologic features • Sever et al : AJR 2011: Sentinel lymph nodes may be identified and localized with microbubbles before surgery

  42. Elastography • Static (Compressive): Manual compression • Shear Wave • Cancers harder and less compressible

  43. ResultsAccuracy of GS US vsElastography plus GS US (Combined US) No statistically significant difference between greyscale US alone and combined US (all confidence intervals for each estimate overlapped)

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