advances in diagnostic imaging · advances in diagnostic imaging mcfarland clinic experience...

ADVANCES IN DIAGNOSTIC IMAGING

DOUG LAKE, MD, MRMD (MRSC)

RADIOLOGIST, MCFARLAND CLINIC, PC

ADJUNCT CLINICAL ASSISTANT PROFESSOR, DEPARTMENT OF RADIOLOGY, STANFORD HEALTH CARE


DISCLOSURES▸ I own shares in the following companies through mutual funds

which are utilized in medical practice and/or health care. Two of

these companies (*) are directly mentioned in this presentation.

▸ *General Electric (GE) (0.67% of portfolio)*

▸ *Hologic, Inc. (0.09% of portfolio)*

▸ UnitedHealth Group Inc (0.74%)

▸ Allergan (0.50%)

▸ Intuitive Surgical Inc (0.48%)

▸ New Link Genetics (0.26%)

▸ Medtronic (0.19%)

▸ McKesson (0.04%)


OVERVIEW

▸3D breast tomosynthesis

▸Tumor Response Assessment

▸Radiation dose reduction project

▸Hemangioma…or something else?


HEMANGIOMA

▸ Benign tumor composed of multiple vascular

channels lined by endothelial cells supported

by thin fibrous stroma

▸ Best diagnostic clues:

▸ On US, well-defined, uniformly

hyperechoic mass. May see posterior

acoustic enhancement.

▸ On CT, peripheral nodular enhancement

on arterial phase scan with slow,

progressive, centripetal enhancement

isodense to vessels.

▸ On MRI: Very T2 hyper intense, with post-

gadolinium nodular progressive

enhancement isodense to vessels

Images from StatDx, Michael Federle, MD FACR


HEMANGIOMA

Images from StatDx, Michael Federle, MD FACR

▸ Benign tumor composed of multiple vascular

channels lined by endothelial cells supported

by thin fibrous stroma

▸ Best diagnostic clues:

▸ On US, well-defined, uniformly

hyperechoic mass. May see posterior

acoustic enhancement.

▸ On CT, peripheral nodular enhancement

on arterial phase scan with slow,

progressive, centripetal enhancement

isodense to vessels.

▸ On MRI: Very T2 hyper intense, with post-

gadolinium nodular progressive

enhancement isodense to vessels


HEMANGIOMA?


A. Hemangioma

B. Hepatocellular carcinoma

C. Metastases from unknown primary malignancy

D. Focal nodular hyperplasia

E. Hepatic cyst


DIGITAL BREAST TOMOSYNTHESIS

▸ Approximately 231,840 new cases of invasive breast cancer and

40,290 breast cancer deaths expected in 20151

▸ Mammographic screening can reduce breast cancer deaths by 30%2

▸ Digital mammography (DM) provide a two-dimensional image of a

three-dimensional structure and superimposition of normal tissue can

obscure masses or other important features of malignancy3

1: DeSantis CE, Fedewa SA, Sauer AG, et al (2016). Breast Cancer statistics, 2015: Convergence of

incidence rates between black and white women. CA: A Cancer Journal for Clinicians, 66: 31-42.

2: Tabar L, Vitak B, Chen TH, et al. Swedish Two-County Trial: impact of mammography screening on

breast cancer mortality during 3 decades. Radiology 2011; 260 (3): 658-663.

3: Roth RB, Maidment AD, Weinstein SP, et al. Digital Breast Tomosynthesis: Lessons Learned from

Early Clinical Implementation. Radiographics 2014; 34: E89-E102.



▸ DBT is a “better mammogram”

▸ Multiple low dose projection x-ray images are obtained along

an arc1

▸ X-ray tube pivots in an arc of varying degrees (15-50)1

▸ 3-dimensional DBT images are reconstructed from

projection images by mathematical equation (FBP or IR)1

▸ In all manufacturers, multiple 2D images are created in thin

1 mm increments and available for display1

1: Roth RB, Maidment AD, Weinstein SP, et al. Digital Breast Tomosynthesis: Lessons Learned from



TRADITIONAL 2D DIGITAL MAMMOGRAPHY



From: Peppard HR, Nicholson BE, Rochman CM, et al. Digital Breast Tomosynthesis in the Diagnostic Setting:

Indications and Clinical Applications. RadioGraphics 2015; 35:975–990.

Roth RB, Maidment AD, Weinstein SP, et al. Digital Breast Tomosynthesis: Lessons Learned from




▸Multiple low dose projection x-ray images are obtained along an arc.

▸X-ray tube pivots in an arc of varying degrees (15-50).

▸3-dimensional DBT images are reconstructed from projection images.

▸ In all manufacturers, multiple 2D images are created in thin 1 mm increments and available for display.



15 projection images x Filtered Back Projection (FT) =

1 mm image set through the breast.



▸ Largest prospective trial of 12631 patients comparing digital

mammography with digital breast tomosynthesis

▸ 15% reduction in recall rate1

▸ 27% increase in cancer detection rate1

▸ Similar to another trial

▸ 15% reduction in recall rate2

▸ 29% increase in cancer detection rate2

1 Skaane P, Bandos AI, guilin R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based

screening program. Radiology 2013; 267 (1):47-56.

2 Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography.

JAMA 205; 311(24):2499-2507.



▸ Breast cancer screening; looking for mass, calcifications or

architectural distortion

▸ Architectural distortion much better seen at DBT

▸ 268 BI-RADS 4 or 5 screening detected lesions with DM and DBT3

▸ 7% (19 of 268) were occult at DM and only seen at DBT3

▸ 10 of 19 (53%) were invasive breast cancers3

▸ 7 of 10 ILC, 3 of 10 IDC3

3: Ray KM, Turner E, Sickles EA, Joe BN. Suspicious findings at digital breast tomosynthesis occult to

conventional digital mammography: imaging features and pathology findings. Breast J 2015;21(5):538-542.

From: Strategies to Increase Cancer Detection: Review of True-Positive and False-Negative Results at

Digital Breast Tomosynthesis Screening, Radiographics 2016; 36: 1954-1965.

CC DM (left) and CC DBT (right) images demonstrate architectural distortion visible in the lateral breast on DBT images only.



Pathology: 6 cm invasive lobular carcinoma.



▸ Quasi-three-dimensional information from DBT allows

triangulation of subtle one-view-only lesions so that further

targeted imaging (US>MRI) is possible.

▸ In a study of 115 malignant lesions, 35% were better or only

seen on DBT CC view whereas only 11% were better or only

seen on MLO view4

▸ Another study of 34 mixed benign and malignant lesions,

15% were better seen at CC DBT5

4 Beck N, Butler R, Durand M, et al. One-view versus two-view tomosynthesis: a comparison of breast cancer visibility in the mediolateral

oblique and craniocaudal views. Presented at the annual meeting of the American Roentgen Ray Society, Washington, DC, April 2013.

5 Rafferty EA, Niklason L, Jameson-Meehan L. Breast tomosynthesis: one view or two? [abstr]. In: Radiological Society of North America

scientific assembly and annual meeting program. Oak Brok, Ill: RSNA, 2006; 225.





Pathology results: Intermediate grade invasive ductal carcinoma.





Pathology results: Intermediate grade invasive ductal carcinoma with DCIS.



▸ Many trials and data, but the biggest was published in 2014 in JAMA6

▸ Breast Cancer Screening Using Tomosynthesis in Combination with Digital

Mammography

▸ 454,850 exams

▸ Period 1: 2010-2011 (Digital mammography)

▸ Period 2: 2011-2012 (3D breast tomosynthesis + digital mammography)

▸ Major outcomes:

▸ Increased cancer detection rate: 4.2 to 5.4 per 1000

▸ Decreased callback rate: 107 to 91 per 1000 (ie, 10.7% to 9.1%)

6 Friedewald SM, Rafferty EA, Rose SL, et al. Breast Cancer Screening Using Tomosynthesis in

Combination with Digital Mammography. JAMA 2014;311(24):2499-2507.


▸ McFarland Clinic Experience

▸ Compared our final year at full field digital mammography (2011) to our most

recent complete year of DBT (2015) in a manner identical to the 2014 JAMA

article (2011 vs 2012).

▸ Paper does not specify sites, but authors from: Caldwell Breast Center Park

Ridge IL, MGH Boston MA, TOPS breast center Houston TX, Solis Women’s

Health Dallas TX, Yale New Haven CN, Case Western Reserve Cleveland OH,

Washington Radiology Associates Fairfax VA, Radiology Associates of

Hollywood FL, Albert Einstein Health Care Network Philadelphia PA, Evergreen

Breast Health Center Kirkland WA, Sanford Breast Health Institute Sioux Falls

SD, Sally Jobe Denver CO, Lincoln Breast Health Phoenix AZ, ICON Clinical

Research San Francisco CA, University of Pennsylvania Philadelphia PA



Site # radiologistsAcademic or

nonacademicPeriod 1 cases Period 2 cases

Recall rate digital

(%)

Recall rate DBT

(%)

Cancer detection

digital per 1000

Cancer detection

DBT per 1000

1 7 A 10746 4366 13.0 10.8 4.1 7.3

2 10 N 19830 7909 7.7 7.3 4.8 4.9

3 6 A 10753 14014 10.4 8.9 4.4 5.4

4 7 A 12533 8607 11.1 7.9 4.1 5.8

5 13 N 26502 3640 13.0 8.8 3.1 3.8

6 18 N 25488 5868 9.4 11.2 6.1 7.5

7 20 N 22606 2613 6.6 8.4 4.5 3.1

8 6 N 16694 16149 11.4 8.5 4.6 5.0

9 3 N 4801 16269 17.4 16.1 2.3 6.0

10 5 A 17623 24281 9.0 7.8 2.4 4.8

11 20 N 53181 24281 15.4 13.8 4.3 6.3

12 12 A 40382 34119 7.2 6.0 4.7 5.2

13 12 N 20048 29948 7.9 5.2 4.1 5.1

Study average 10.7 5A 8N 21629 13358 10.7 8.9 4.3 5.4

McFarland 8 N 16548 18067 11.6 7.4 4.3 5.0

DIGITAL BREAST TOMOSYNTHESIS -MCFARLAND EXPERIENCE


Site# radiolo-

gists

Academic

or non-

academic

Period 1

cases

Period 2

cases

Cancer

detection

digital per

1000

Cancer

detection

DBT per

1000

Recall

rate

digital (%)

Recall

rate DBT

(%)

Study average 10.7 5A 8N 21629 13358 4.3 5.4 10.7 8.9

McFarland 8 N 16548 18067 4.3 5.0 11.6 7.4

+16% (+15%, +15%)

-36% (-27%, -29%)

DIGITAL BREAST TOMOSYNTHESIS -MCFARLAND EXPERIENCE

6 Friedewald SM,

Rafferty EA, Rose

SL, et al. Breast

Cancer Screening

Using

Tomosynthesis in

Combination with

Digital

Mammography.

JAMA

2014;311(24):2499-

2507.

1 Harvey JA, Mahoney MC, Newell MS, et al. ACR Appropriateness Criteria Palpable Breast Masses.

Journal of the American College of Radiology November 2016 Vol. 13, Issue 11, e31–e42

18-29 yo: Ultrasound followed by mammogram for area of palpable concern

in age 18-29 if there is no corresponding abnormality found by the ultrasound

after radiologist has reviewed the ultrasound.

<18 yo: Ultrasound only. Mammogram performed only if advocated for by

the patient/parents/guardian after discussion with the radiologist.

1 Harvey JA, Mahoney MC, Newell MS, et al. ACR Appropriateness Criteria Palpable Breast Masses.

Journal of the American College of Radiology November 2016 Vol. 13, Issue 11, e31–e42

MRI Abdomen without and with gadolinium from an outside institution 2/11/2016


A. Hemangioma




E. Hepatic cyst

PET-CT McFarland Clinic 5/26/2016

MRI Abdomen without and with gadolinium McFarland Clinic 11/2016.


TUMOR RESPONSE ASSESSMENT▸ Response Evaluation Criteria In Solid

Tumors (RECIST)

▸ First published February 2000

▸ Most recently revised 2009 (RECIST 1.1)

▸ Standardized assessments

▸ Complete response/remission (CR)

▸ Partial response (PR)

▸ Progression of disease (PD)

▸ Stable disease (SD)

1 Tirkes T, Hollar MA, Tann M, et al. Response Criteria in Oncologic Imaging: Review of Traditional and

New Criteria. RadioGraphics 2013; 33:1323–1341


RECIST 1.1 - HOW IT WORKS

RECIST 1.1

Lesions 5/2

Measurement LA (SALN)

PD/PR 20%/30%

New lesions PD





Target Non target New lesion Overall

CR CR No CR

PR Non PD No PR

SD Non PD No SD

PD Yes or no Yes or no PD

Any PD Any PD

Any Any Yes PD1 Tirkes T, Hollar MA, Tann M, et al. Response Criteria in Oncologic Imaging: Review of Traditional and




SD = STABLE DISEASE

PD = PROGRESSIVE DISEASE

PR = PARTIAL RESPONSE

CR = COMPLETE REMISSION

baseline follow up 1 follow up 2 follow up 3

-30% = PR

NADIR

SD = + 4%

+20% = PD


TUMOR RESPONSE ASSESSMENTCriteria Tumor/Modality

RECIST 1.1 Most tumors

PERCIST 1.0 PET

Cheson PET

Lugano Diffuse Large B-cell Lymphoma (DLBCL)

Choi GIST

NRC/Lee (New Response Criteria) NSCLC

RANO (Response Assessment in Neuro-Oncology) Glioblastoma

MASS (Morphology, Attenuation, Size, Structure) RCC

irRC/irRECIST Melanoma

mRECIST HCC


RECIST 1.1 VS LUGANO

RECIST 1.1 Lugano

Lesions 5/2 6

Measurement LA or (SALN)LA x SA = PPD

PPD1 + PPD2 + etc = SPD

CRDisappearance of target & <10mm

LNSA

<1.5 cm LNLA & disappearance of non-nodal dz

PD/PR +20%/-30%+50% & +0.5(<2cm) or

+1(>2cm)/-50%

New lesions PD PD

PET assessment No (PERCIST 1.0) Yes




TUMOR RESPONSE ASSESSMENT▸ Limitations

▸ Inconsistent measurements

between readers and even with

same reader1

▸ Difficulty with measuring ill-

defined lesions1

1 Tirkes T, Hollar MA, Tann M, et al. Response Criteria in

Oncologic Imaging: Review of Traditional and New

Criteria. RadioGraphics 2013; 33:1323–1341


A. Hemangioma




E. Hepatic cyst


RADIATION DOSE REDUCTION PROJECT

▸ CT abdomen and pelvis without contrast for renal colic

symptoms

▸ Guidance from American College of Radiology states these

exams should be performed with an average dose-length-

product (DLP) of 200 mGy-cm (3 mSv).

▸ Guidance issued in 2007.

▸ ACR Dose Registry analysis in 2013 showed significant

heterogeneity nationwide regarding adoption.

What is the lowest minimum

dosing that can cause harm?

100 mGy = 100 mSv

What is the lowest minimum

dosing that can cause harm?

0.1 Sv = 100 mSv

499

153

452572

308372

1,053

525

1,363

1,130

860751

1,494

1,205

2,435

2,618

2,787

1,657

0

750

1500

2250

3000

MGMC GE Lightspeed 16 CT1 MGMC GE Lightspeed 64 CT2 McF Ames Toshiba Aquilon McF Marshalltown Toshiba Aquilon CIH GE Lightspeed CIG GE Optima 660

Minimum DLP Mean DLP Maximum DLP

Orange line: National average

from 49,903 exams compiled

from 2011-2013 by ACR dose

registry

(DLP 746, approx 11.2 mSv).

Yellow line: Midwest average from

14,642 exams compiled from

2011-2013 by ACR dose registry


Green line: Recommended

average for these exams by

ACR (DLP=200, 3 mSv).

Red line: Average dose from 55

patients imaged on the 6 CT

scanners surveyed.

(DLP 964.9, approx 14.5 mSv)

3000 DLP approximates 45 mSv.

964.9 DLP approximates 14.5 mSv.



499

153

452572

308 372

1,053

525

1,3631,130

860751

1,494

1,205

2,4352,618

2,787

1,657

0

750

1500

2250

3000

MGMC GE Lightspeed 16 CT1 MGMC GE Lightspeed 64 CT2 McF Ames Toshiba AquilonMcF Marshalltown Toshiba Aquilon CIH GE Lightspeed CIG GE Optima 660

Minimum DLP Mean DLP Maximum DLP




registry











scanners surveyed.

(DLP 964.9, approx 14.5 mSv)

540250 171 223 281 225

1,321

881

274

886

341 336

1,224

913

399

812

348 334

1598

1425

1067

1613

426 382

0

750

1500

2250

3000

MGMC GE Lightspeed 16 CT1 MGMC GE Lightspeed 64 CT2 McF Ames Toshiba Aquilon McF Marshalltown ToshibaAquilon

CIH GE Lightspeed CIG GE Optima 660

Minimum DLP Median DLP Mean DLP Maximum DLP




registry











scanners surveyed.

(DLP 690, approx 10.3 mSv)

Initial goal: We wanted to achieve

an average of 2x the

recommended ACR average

(DLP=400, 6 mSv).

2015

data

2016

data

A. Hemangioma




E. Hepatic cyst

Hemangiomas and a breast carcinoma met - Both previously treated with Avastin

advances in diagnostic imaging · advances in diagnostic imaging mcfarland clinic experience...

Documents