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Breast Imaging!Ravi Adhikary, MD!

ACS Estimated Cancers Statistics 2014!

New Cases in Women! Deaths in Women!

Breast! 232,670 (+67,570 in situ)! 40,000!

Colon! 48,380! 24,040!

Cervical! 12,360! 4,020!

Lung! 108,210! 72,330!

Pancreas! 22,840! 19,420!

Screening Mammography!•  Women of average breast cancer risk !

•  Annually starting at age 40!

•  Women with an increased risk!

•  BRCA1/2 mutations, or untested with first degree relatives with BRCA!

•  Yearly, starting by age 30, not before 25!

•  >20% lifetime risk of breast cancer by family history, women with mothers and sisters with premenopausal breast cancer!

•  Starting by age age 30, or 10 years earlier than the diagnosis of the youngest affected relative, but not before age 25!

•  History of mantle radiation (for Hodgkin’s disease)!

•  Yearly starting 8 years after radiation therapy, not before 25!

•  Women with lobular neoplasia, ADH, DCIS, invasive cancer or ovarian cancer!

•  Yearly from time of diagnosis!

Screening Mammogram!Trial! Age! Follow-up years! Mortality Reduction!

Health Insurance Plan of Greater NY (1963-1969)! 40-64! 18! 23%!

Malmo Mammographic Screening (1976-1986)! 45-69! 18-24! 19%!

Swedish Two County Trial (1979-1988)! 40-74! 20! 32%!

Edinburgh Trial (1979-1988)! 45-64! 14! 29%!

Canadian National Breast Screening Study

(1980-1987)!50-59! 13! -2%!

Stockholm trial (1981-1985)! 40-64! 8! 20%!

Gothenburg Breast Screening Trial

(1982-1988)!40-59! 14! 23%!

UK Age Trial (1991-2005)! 39-41! 10! 17%!

Mammogram!

•  Masses!

•  Calcifications!

•  Architectural distortion!

•  Asymmetries!

•  Other features!

Breast Density!

•  A: Almost entirely fatty!

•  B: Scattered areas of fibroglandular density!

•  C: Heterogenously Dense!

•  D: Extremely dense!

Potential Problems With Dense Breast Tissue!

•  Increased Relative Risk!

•  Category D vs A: 4 to 6!

•  Category C vs average: < 1.2!

•  Category D vs average: <2.1!

•  Decreased sensitivity of mammography!

•  Category D vs A: Sensitivity decreased 26%!

•  Category C vs average: Sensitivity decreased 7%!

•  Category D vs average: Sensitivity decreased 13%!

Breast Density Legislation!

•  Women with dense or heterogeneously dense breast tissue receive a letter!

•  New York State has passed legislation and letters have been going out since 2013!

New York State Law!•  Your mammogram shows that your breast tissue is dense. Dense breast

tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer.!

•  This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.!

Possible Approaches!

•  No further screening!

•  Additional screening with ultrasound and MRI!

•  Benefits may be found in those women who have other risk factors beyond just density!

Ultrasound Screening!•  In 6 studies conducted between between 1995 - 2008

evaluating ultrasound screening:!

•  Involving 40,544 women!

•  Cancer detection ranged from 2.3-4.6/1000 screened, overall 3.4/1000!

•  Mean size of cancer ranged from 9.1-11 mm!

•  83%-100% of cancers found to be invasive!

•  86%-100% of cancers found to be node negative!

Ultrasound Screening!•  Cancers found in screeners:!

•  Low risk!

•  1.6/1000!

•  Intermediate Risk!

•  6.7/1000!

•  High risk!

•  11.5/1000!

Ultrasound Screening!•  Pros!

•  Does not require ionizing radiation!

•  No intravenous contrast required!

•  Well tolerated by patient!

•  Availability!

•  Relatively inexpensive!

•  Cons!

•  Does depend on operator!

•  High rate of BI-RADS 3 lesions !

•  Positive predictive value of biopsies is low !

•  Yield of cancer in those women of low risk other than breast density is relatively low!

Breast Ultrasound!

•  Masses!

•  Calcifications!

•  Other findings!

MRI Screening!•  Not just for dense breasts!

•  High risk groups!

•  Generally starting by age 30!

•  10 years before !

•  >20-25% lifetime risk of breast cancer!

•  BRCA carriers, 1st degree relative of BRCA carrier!

•  Chest radiation (for Hodgkin’s disease)!

MRI Screening!•  EVA Trial!

•  Multicenter study!

•  Evaluate contribution of MG, US, MRI!

•  687 women with >20% lifetime risk!

•  Cancer yield!

•  MG: 5.4!

•  US: 6.0!

•  MG + US: 7.7!

•  MRI: 14.9!

•  MG + MRI: 16.0!

•  MG + MRI + US: 16.0!

MRI Screening!•  Those with claustrophobia may not be able to tolerate

the exam!

•  Pacemaker!

•  Renal function !

•  Contrast allergy!

•  Limited availability!

•  Expensive !

Breast MRI!

•  Mass!

•  Non mass enhancement!

•  Focus!

•  Other findings!

BI-RADS Assessment!Assessment! Management! Likelihood of Cancer!

Category 0: Incomplete! Recall for additional imaging and/or comparison with priors! N/A!

Category 1: Negative! Routine Screening! Essentially 0%!

Category 2: Benign! Routine Screening! Essentially 0%!

Category 3: Probably benign! Short interval follow-up! >2%!

Category 4: Suspicious! Tissue diagnosis!

2%-95%!4A: 2%-9%!

4B: 10%49%!4C: 50-49%!

Category 5: Highly suggestive of malignancy! Tissue Diagnosis! >95%!

Category 6: Known biopsy-proven malignancy! Surgical excision when appropriate! N/A!