Breast imaging Disclosures Update 2009 - scripps.org · FJ case presentation: PEM FJ case presentation: PEM Posterior location requires additional views to see lesion Exaggerated

Scripps Clinic/Scripps Green Hospital Grand RoundsWednesday, Sept. 2, 2009

www.scripps.org/conferenceservices

Breast imaging Update 2009:Incorporating functional breast imaging

Marie Tartar, M.D.Scripps Green Hospital, La Jolla CADirector, Advanced Breast Imaging

Disclosures

Site principle investigator: Prospective Multicenter Study of the Role of PEM in Pre-Surgical Planning for Breast Cancer, 2006-08 Sponsored by Naviscan

PET Systems, San Diego

Courtesy NaviscanPET Systems

Courtesy Dilon

BSGI vs. PEM comparison 48 y.o. female with new dx

at OSF of Lt UOQ IDC (1 cm by US)

40 y.o. asx female with extensive suspicious Lt lateral microcalcificationson baseline mammo

Staging: whole body PET



Local staging: PEM BSGI: a new era of scintimammography

Improved resolution Detectors closer to

radiation sourceViews analogous

to mammographyPlanar

The clinical relevance of mitochondrial bindingand of cellular concentrations in vitro have notbeen established.

Courtesy of DuPont Pharmaceuticals

MechanismScintimammography: Meta-analysis

Meta-analysis of single site & multi-center trials since 1/1997 with >100 pts

Nucl Med Commun 2006, 27:589–594

2424 pts from 12 single site trials, 1997-2005 105-353 pts Sensitivity 85% Specificity 84%

3049 pts from 5 multi-center trials, 1997-2003 246-1243 pts Sensitivity 85% Specificity 83% Up to 3 readers/site,

interpreted w/o clinical data

Scintimammography

International prospective evaluation of scintimammography with Technetium 99m sestamibi

Sampalis FS, et al. AJS 185 (2003), 544-549

Multicenter, prospective trial

1734 women enrolled, data complete on 1243

Sensitivity 93%

Specificity 87%,

PPV 58%,

NPV 98%

Studies performed on BODY gamma cameras

BSGI indications

Known or suspected cancer Assess disease extent (lesion

size) Assess rest of cancer breast

& opposite side Primary search (axillary LN

presentation)

High risk screening

Difficult to image pt Implants Injections

Triage/problem solving Multiple masses or clusters

of microcalcifications

Suspicion of recurrence

Monitoring of treatment (neo-adjuvant chemo)

Alternative to MRI for any of the above

PEM indications similar



Case presentation: CC

48 y.o. female with new dxat OSF of Lt UOQ IDC (1 cm by US)

PMH: FA 12 o’clock (bxproven)

Case presentation: CC

Case presentation: CC Case presentation: CC

Outcome Pt elected bilateral simple

mastectomy

Lt mastectomy path 3.5 cm UOQ IDC with

lymphovasc invasion +multifocal & multicentric,

multiple tumor nodules in other quadrants

Rt prophylactic mastectomy path: -

Case presentation: KS

63 y.o. female

PMH: BCT 14 yrs before for Lt DCIS

Routine mammo Suspicious on right ? masses




Case presentation: KS Case presentation: KS

US guided bx X 2 Invasive mammary ca X 2

Mastectomy

2 invasive mammary cancers 9 o’clock: 2 cm, features

of lobular cancer with tubule formation

11 0’clock: 1.5 cm

Case presentation: BB

76 y.o. female with abnormal mammogram


Case presentation: BBHow many abnormalities?


US bxs X 3 1 o’cl: benign 2 o’cl: benign 5-6 o’cl: IDC

BSGI: predicts unifocaldisease

Pathology: 1 cm IDC 3/12 LNs+

(LNs – by US & BSGI)



Do we need additional breast imaging modalities?

How reassuring is CI? NPV of mammo & US

together in evaluation of palpable lump 95%

All modalities miss breast cancers!

CI often underestimates the extent of cancer

Case SC: 56 y.o. female with stereo bx dx ILC & DCIS of Lt UOQ clustered microcalcifications

Case presentation: SC

SC: What is the extent of disease? SC: What is the extent of disease?

SC: What is disease extent?

Mammo: 1 cm

MRI: 8 cm

PEM: 4.8 cm

Pathology: 5 cm ILC and DCIS

Surgical treatment changed from BCT to mastectomy

Tip of the

ICEBERG

Case SC summary Mammo screening identified pt

as needing further evaluation

Tiny cluster of Ca++ led to dx of unsuspected 5 cm ILC

In pre-AI era: BCT attempt doomed to failure

+ margins Ultimate mastectomy > 2 surgeries

In AI era: PEM & MRI strongly predictive of

need for mastectomy Treatment surgery accomplished

in 1 procedure



Do we need additional breast imaging modalities?

Mammography remains the cornerstone of breast imaging

Digital established by DMIST trial to improve breast cancer detection in pts < 50, pre-menopausal pts & pts with dense breasts Pisano ED, et al.

Diagnostic Performance of Digital versus Film Mammography for Breast-Cancer Screening N. Engl. J. Med., Oct 2005; 353: 1773 - 1783.

Mammography: the cornerstone of breast imaging

Mammography limited by breast density in mass detection

Mammography excels at microcalcificationdetection

Overall mammographic sensitivity for breast cancer detection 80% 45% in extremely dense 100% in fatty breast

40 y.o. asx female, baseline screening

Targeted ultrasound: a valuable complement to mammography

When a mass is suspected or ?ed by BSE or PE by mammography

Evaluation incomplete w/o US

If solid/suspicious mass seen by US, US is most comfortable method for pt of bx guidance

US guided core bx: IDC

Case VK: was is disease extent ?

What other tools do we

have?

What other tools do we have?

MRI Not affected by breast

density or implants Best for chest wall Hormonal effects

problematic Timing preferable if pre-

menopausal 2cd week cycle ideal

Specificity problematic Best case: 70% Many FPs Many add’l bxs



Case VK: Disease extent?Index ca

intense FDG uptake

High, but uniformbackground uptake

Pathology: 3.2 cm IDC

BSGI vs. PEM comparison

Where does functional breast imaging fit in?

Should all newly diagnosed breast cancer pts have AI?

PEM/BSGI advantages vs. MRI

Functional!

Less hormonal influences Timing less critical

Cheaper

Lower FP rate/higher specificity

Much easier to learn to read

Thanks for coming!

Merci pour votre attention!



PEM vs. BSGI: US snapshot Case presentation: BM

48 y.o. female with dense breasts

New palpable lump periphery of Lt breast at 11 o’clock

FH: maternal aunt, age 39

Case presentation: BM Case presentation: BM

Case presentation: BM Case presentation: BM

US bx: IDC (tubular form)Lumpectomy:

1.4 cm tubular IDC



Case presentation: RN

60 y.o. female

PMH: lt surgical excision for ADH 3 years before

Screening mammogram Rt UOQ arch distortion?

Case presentation: RNRT UOQ architectural

distortion US: suspicious mass

US bx: IDC


US bx: IDC

Case presentation: RNPEM: multi-focal

disease?


Rt US-guided localization X 2

Pathology IDC X 2

11 o’clock: 1.4 cm 9 o’clock: 0.6 cm

Case presentation: TJ

53 y.o. female

MD palpated Lt lateral breast lump on PE

Mammo + spiculated mass



TJ case presentation: US

US:

TJ case presentation: MRI

? tiny satellites

TJ case presentation: MRIDynaCAD: index

cancerDynaCAD: suspected

satellite

TJ case presentation: PEM? Unifocal disease

TJ case presentation: pathology

MRI guided bx of posterior focus ILC and ALH

Mastectomy 2 cm invasive tubulolobular

carcinoma 1.6 mm focus of cancer

infero-lateral to index 5 benign LNs

Assessment: MRI depiction of extent more

accurate in this pt than PEM ?significance of additional

disease ? PEM FN due to size

Case presentation: FM

49 y.o. asymptomatic female

Screening mamm new Rt lat

microcalcifications

Stereo bx ILC and DCIS



FM case presentation FM case presentationClip

2cd, unsuspected mass

FM case presentationAI shows 2cd,

unsuspected ca MRI bx (2 cm from index)

ILC and DCIS

Still BCT eligible, but small breasts

Pt elected mastectomy

Pathology 2 ILCs, 2 cm apart 0.3 and 2 cm 2 neg sentinel LNs

Dense breasts AI>CI PEM=MRI

Case presentation: JP

64 y.o. female

Screening mammo increased Ca++ Rt 12

o’clock

Stereo bx 0.3 cm IDC & high grade

DCIS

Case presentation: JP JP case presentation: MRI



JP case presentation: Rt PEM JP case presentation: Lt PEM

JP case presentation

Outcome:

Lt MRI-guided bx: Intermediate grade DCIS

Surgery: bilateral lumpectomies

Pathology Rt: 1.7 cm IDC with 10% DCIS Lt: DCIS (3 cm)

AI>CI

MRI>PEM

Case presentation: BJ

65 y.o. female

Lt UOQ thickening?

Mamm: Rt UOQ AD?

Case presentation: BJSpot compression

Rt MLOSpot compression

Rt CC

BJ Case presentation: USRt UOQ US:

ILC & LCIS on bx Lt UOQ US



BJ Case presentation: PEMRt MLO PEM +, but to what extent?

BJ Case presentation: PEM

Rt CC mammogram Rt CC PEM

BJ Case presentation: MRIBy MRI….

What about Lt side? Rt ILC much more extensive

than 3 cm suggested by US

By MRI, extent >6 cm

BJ Case presentation: PEMhow about the left side?

Prospectively: negative (?)

Correlated with MRI?

BJ Case presentation: Outcome

Bilateral mastectomy Rt-5.5.cm ILC; 10/11 LNs +

Lt-1.7 cm ILC, 2 - LNs

Case presentation: FJ

57 y.o. female with palpable right axillary lump

Negative mamm earlier same year

US Abnormal 1.6 cm ax mass Suspicious 2.1 cm mass rt

lateral breast, 9 o’clock



FJ case presentation: US bx X 2

IDC, high grad DCIS (no LN tissue seen)

IDC, high grade DCIS

FJ case presentation: MRIRt known IDC well seen.

2cd abnormality in retroareolar area?

FJ case presentation: PEM FJ case presentation: PEMPosterior location requires

additional views to see lesion Exaggerated CC

FJ case presentation: PEMWhat about the retroareolar area?

MRI bx recommended

Pt elected mastectomy

Pathology 2 cm IDC, high grade DCIS

(EIC) ADH in retroareolar area 4/11 LNs +

ADH High risk lesion Overlaps in histologic

spectrum with DCIS How important to detect?

Difficult PEM cases: GMHistory

59 y.o. female

Screening mammo Lt UOQ posterior clustered

microcalcifications

Stereo bx Intermediate grade DCIS Specimen included chest

wall skeletal muscle

MLO:



Difficult PEM case: GM

CC: Significance of linear

uptake DCIS? Post-biopsy change?

Difficult PEM case: GMMicrocalcifications

post UOQ:Stereo bx scout:

Difficult PEM case: GM

Post-stereo bx

GM difficult PEM case: MRI

Axial STIR:Axial T1:

Difficult PEM case: GMSagittal:

Difficult PEM case: GM Knowledge of large post-bx

hematoma changes apparent significance of PEM findings

? Mostly post-bx changes

Pathology: 2.4 cm DCIS 1 - SLN



“Normal” post-bx changes on PEM

BM 61 y.o. asx female

Screening mammo Lt lateral (3 o’clock)

microcalcifications

Stereo bx High grade DCIS, ADH,

sclerosing adenosis 2-3 cm post-bx hematoma

noted

“Nl” post-bx changes: BM

Pathology: 1.5 cm DCIS

Small post-bx hematoma

“Nl” post-bx changes on PEM & MRI:BM

Sagittal MRI MPR MLO PEM

Borderline/high risk lesions: VK

40 y.o. female

Screening mammo Dense! Lt postero-lateral

mass


US guided bx IDC

Lt UOQ US


MRI: MIPMRI: ax subtraction,

minute 1



Borderline/high risk lesions: VKIndex ca

intense FDG uptake

High, but uniformbackground uptake

VK-borderline/high risk lesion:outcome

Rt side pre-op MRI bx Radial scar Negative on PEM

Bilateral lumpectomies Rt-radial scar, columnar

cell change, FCC, fibroadenomatoid change

Lt-3.2 cm IDC, 1 - SLN

Case presentation: YM

56 y.o. female with palpable Lt UOQ lump

Worked up with mammo & US

US guided bx-IDC

Case presentation: YMCC spot US Lt UOQ

Case presentation: YMDisease extent on PEM?MLO PEM CC PEM

Case presentation: YMDisease extent on MRI?

? Second linear site



YM case presentation: outcome

MRI bx of 5 o’clock suspected second lesion IDC

Pt underwent mastectomy

Pathology showed IDC X2 2 o’clock: 1.8 cm 5 o’clock: 1.4 cm 1 + SLN, 10 add’l LNs –

(1/11 LN +)

PEM missed second primary Possible contributing factors

Small size, linear configuration?

Large breast size? Low metabolic rate?

Difficult case: FJ

59 y.o. female

Abnormal screening mammo Mass UOQ

Difficult case: FJ Difficult case: FJUS guided bx X 2:

ILC X 2

Difficult case: FJ Difficult case: FJ

MRI bx X 2: ILC/LCIS X 2



Difficult case: FJ

MRI easier to interpretILC-low metabolic rate

tumor with FDG PETTumor hard to

distinguish

Final pathology3 sites, ILC & invasive tubulo-lobular carcinomaLargest 3.8 cm @ 9-11 o’clock

PEM interpretation:potential pitfalls

51 y.o. female with Rt 6 o’clock micro-calcifications on mammogram

Stereo bx: IDC & DCIS

Post-biopsy uptake Post-biopsy uptake

PEM interpretation:potential pitfalls

Injection site imaging



Injection site imaging PEM case presentation 40 y.o. asx female

Mammo Extensive suspicious Lt lateral

microcalcifications Suspicious for DCIS

US Obtained to look for mass(es)

within Ca++ (invasion)

5 masses found 2 bx’d: IDC and high grade

DCIS

PEM case presentation

Pt desired BCT

Extensive staging studies MRI PEM

PEM: MLO & CC

PEM: MLOPEM: CC



MRI & PEM indicate

disease is multi-centricPt treated with neo-adjuvant chemotherapy prior to mastectomy

PEM case presentation: 3007

73 y.o. female Screening

mammo: UOQ mass

PEM case presentation:3007

US

PEM case presentation:3007

PEM case presentation:3007 PEM case presentation:3007multi-centric disease

RA: DCISUOQ: IDC & DCISRx: mastectomy



Case presentation: DJ

60 y.o. asx female Hx: HRT X years Abnormal screening

mamm


Case presentation: DJ MRI interpretation easy in this pt

Low background enhancement Unifocal disease


Case presentation: DJ PEM interpretation

difficult High background

uptake Small lesion size ? Low intrinsic lesion

metabolic rate Outcome

BCT IDC

Case presentation:DJ

?2cd abnormality on PEM in LOQ

US: mass at 5 o’clock US bx: fat necrosis PEM false +



Case presentation

45 y.o. female Screening Call back for ? Rt

UOQ density Not confirmed on

spotsPE: ? ThickeningUS: hypoechoic (?)

mass

US guided bx: IDC, DCIS Disease extent: PEM

Disease extent: MRI Pathology: 6 cm invasive tubulo-lobular cancer with EIC



Case presentation: CL

50 y.o. asx female

Screening mamm Suspicious spiculated Rt 9

o’cl mass

Case presentation: CLUS bx: IDC

CL case presentation: MRI

Rt index IDC well seen

CL case presentation: MRIWhat about the left side?

CL case presentation: PEMRt index IDC +, also Rt ax LN

CL case presentation: PEM

How about the left side? ?LIQ (in retrospect)



CL case presentation: Lt?LIQ Lt MRI bx: LCIS, ID papillomatosis

CL case presentation: outcome

Bilateral lumpectomies

Rt 2.6 cm IDC with low grade

DCIS (<25%) 5/14 LN +

Lt Focal LCIS Complex sclerosing lesion

with FCC PASH

Extent of disease: MB

85 y.o. female

Mamm: extensive UOQ calcifications (multiple clusters)

Stereo bx: intermediate grade DCIS

Extent of disease: MB

Extent of disease: MB Extent of disease: MB



PEM interpretation:background activity

High Homogeneous


Low Uniform


Mild-moderate Patchy

Case presentation: VP

60 y.o. female

Pt felt Rt palpable lump 1 month before mammo

Mammography: Rt lateral subareolar

microcalcifications

Case presentation: VPPalpation guided bx: high grade DCIS with comedonecrosis Case presentation: VP

MRI axial subtraction CC PEM



Case presentation: VPMLO PEM Sagittal MRI MPR

Case presentation: VPOutcome

? Axillary LN involved by PEM & MRI

Normal appearing Rt ax LN FNA’d pre-op Lymphocytes, no cancer

Mastectomy pathology 3 cm DCIS with necrosis SLN negative

Difficult PEM interpretation: DPheterogeneous background uptake

42 y.o. asx female Mammo-small cluster Rt

UIQ microCa++ Stereo bx

Low grade DCIS


Difficult PEM & MRI interpretation: DPheterogeneous background uptake




Difficult PEM & MRI interpretation: DPheterogeneous background uptake

BJ Case presentation: PEM interpretation more difficult with lower metabolic rate tumors

(e.g., ILC)

Case presentation: RNHow about the

left side? Lt MRI guided bx recommended

Mammography: the cornerstone of breast imaging x-ray based process

differentiates between mineral (Ca++), fat, air soft tissue

Compression immobilizes & thins tissue

Summated image Sensitivity 80-85% 5-10% recalled for

add’l views

Case presentation: SC

56 y.o. female

Lt UOQ clustered microcalcifications

Stereo bx-ILC & DCIS

What we’relooking for

Masses



What we’relooking for

Microcalcifications

Change from a prior exam…

can be the only sign of malignancy

Utility of US

Characterize mammographic or palpable masses Cystic Solid

Circumscribed Or NOT

Guide biopsies

Characterizing masses with US:margin analysis

Breast MRI basics: technique

Prone positioningDedicated breast

coilHigh field magnet 1-1.5 T magnet

Enhanced, subtracted dynamic technique

Breast MRI basics: subtraction



Enhancement curve:abnormal wash-out=

angiogenesis

A new tool: Breast MRI CAD

Limitations of mammography:Breast density

Generally greater in younger pts than older

Most people involute with age

Relatively little relation to weight, size

Sensitivity decreases with increasing density

newly recognized as independent risk factor for BC

Case presentation: BBHow many abnormalities?

Sonographic findings frequently non-specific



Case VK: was is disease extent?

MRI: MIPMRI: ax subtraction,

minute 1

Case VK: outcome

Rt side pre-op MRI bx Radial scar Negative on PEM

Bilateral lumpectomies Rt-radial scar, columnar

cell change, FCC, fibroadenomatoid change

Lt-3.2 cm IDC, 1 - SLN

Pathology: 3.2 cm IDC

Functional imaging: PET

Tracks physiologic processes using labeled biomolecule (glucose, AA, H2O)

FDG PET uses glucose analog to track glucose metabolism

Rapidly growing tumor cells have greater energy requirements/ glucose utilization than normal cells

Advantages subradiographic dz

mets in nl size LNs complements

anatomic imaging modalities

BSGI advantages/disadvantages

Advantages of BSGI No advance preparation

Cheaper radioisotope

Cheaper

No uptake period

Disadvantages of BSGI Planar

Fuzzier than PEM

No currently available biopsy capability

PEM advantages/disadvantages

PEM advantages “Sharper”

Tomographic

Biopsy capability now

Can be performed in conjunction with WB PET

PEM disadvantages Pt must fast > 4 hours

Glucose must be checked & normal

Low metabolic rate tumors variable in FDG avidity

More expensive

Case presentation: CCMulti-centric disease suggested, MRI recommended, prior Lt US targeted



Does this matter?

Conventional breast imaging(mammography & US) frequently underestimate the extent of breast cancer in comparison to histology

Some difficult questions

Time for a break!High Risk Screening

BREAST IMAGING:Cancer Yield of Mammography, MR, and US in High-Risk Women: Prospective Multi-Institution Breast Cancer Screening Study

Lehman CD, et al. Radiology, Aug 2007; 244: 381 - 388.

195 women enrolled over 6 months 171 completed all

modalities within 90 days

High risk BRCA-1 (31)/BRCA-2 (36) >20% probability BRCA

16 abnormalities/bxs performed

6 cancers dx’d All 6 found by MRI Mammo found 2 US found 1 (also found by

mammo & MRI)

Whole breast screening US:the case against it

High risk screening Lehman CD, et al.

Radiology, Aug 2007; 244: 381 - 388. Cancer yield

MRI 3.5% US 0.6% Mammo 1.2%

Dense breast screening

Positron Emission Mammography: PEM

Image: courtesy of Naviscan PET Systems



Resolution: WB PET vs. PEM Case presentation: KS

Normalized Rt CC


Final pathology Mastectomy

2 invasive mammary cancers 9 o’clock: 2 cm, features

of lobular cancer with tubule formation

11 0’clock: 1.5 cm

Focal DCIS also in LOQ & LIQ

Whole breast screening US:

more controversial Results in elevated risk

population (n=2725) Mammographic

sensitivity alone 50% Mammo + US sensitivity

77.5% Berg WA, et al.

Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast CancerJAMA. 2008;299(18):2151-2163.

High likelihood of false positives (9% PPV)

Extremely labor intensive

Breast imaging Disclosures Update 2009 - scripps.org · FJ case presentation: PEM FJ case presentation: PEM Posterior location requires additional views to see lesion Exaggerated

Documents