riga 2016tomocesmcombo

Beyond Digital Mammography.Experience in CESM and

TomosynthesisSana PascalineMohamad Hajaj

KETTERING BSU, KGH, UK

2012

KGH Breast Unit went digital 2010 - 2012

Lower sensitivity in women with dense breasts due to reduced contrast between possible tumour and surrounding breast tissue.

As low as 30% -50% with BRCA gene mutation

Kolb et al `Radiology 2002 oct:225(1)165-75Pisano et al N Engl J Med. 2005:3535:1773-1783Jemal et al Globalcancer statistics.CA Cancer J Clin2011

How good is Digital Mammography?

2013

Tomosynthesis audit

50 patients had both a standard mammogram and a tomosynthesis examination (audit 2013-2014)

All 50 patients were symptomatic

P4/5 Clinical findings

P3 clinical findings – if 2D image is normal or indeterminate

P1/2 Clinical finding – if incidental finding on 2D image

Family history if new mass or stromal deformity on 2D or very dense parenchyma

Tomo audit inclusion criteria

Tomo audit results36 (69%)Patients Tomosynthesis aided diagnosis

extra information 22 patients(62%)more detailed information 7patients (19%)proved abnormality to be NAD7 patients (19&)

Unhelpful when imaging solid & dense masses in very dense breasts – (cheese effect!)

Occupies lots of storage space on archiving systems (200-300)

Disruptive: NHS BSP clinics vs ad hoc tomos in the same room

Tomo is not for breast implants

Normally only one breast imaged

Tomo challenges

Can demonstrate second/satellite lesions that are not found in mammogram (benign or malignant)

Can demonstrate mammographically occult lesions (benign or malignant)

Can provide more detailed information of lesions already seen on the standard digital mammogram.

May prove apparent lesions to be tissue overlap

Tomo benefits

Tomo Cases

33 y.o. Right breast P2 nodularity

Case1

Multiple spiculate lesions and malignant microcalcs

G2 NST and High Grade DCIS

Case 1

53 y.o. P3 lump behind right

breast nipple

Case 2

3 cm IDM behind right breast nipple

Right axillary lymphadenopathy

G3 mixed pleomorphic NSTand classical lobular BCa

Case 2

Case 3

High Grade DCIS

Tomobiopsyand/or

localisation

2015

Contrast Enhanced Spectral Mammography - CESM

Contrast used for years in both CT and MRI Helps to explore angiogenesis in breast cancer Iodinated contrast CT useful for breast cancer (30%

of enhancing nodules on CT were shown to be cancers) NICE guidance for Breast MRI for better staging.

Kettering-2015

Why CESM was introduced?? “ A dual energy technique, used with the introduction of iodinated contrast material”

• To provide better information on the disease extent/staging and uni- vs. multifocality

• To increase cancer detection

• Improve waiting times.

• Make best use of existing equipment / staff

• Keep Mammography relevant

Advice on implementation from NBI Local R&D department/Clinical Governance

approval. Patient information brochure Consent.

Introduction of CESM at Kettering

P4-P5 symptomatic patients*

Age criteria without eGFR: 35-70 years

Patients older than 70 years needs eGFR established prior to CESM.

Who is eligible?

First Tool Modality Second Tool Modality

One stop Symptomatic patients with P4/5 lumps.

One stop Symptomatic patients with P3/4 lumps following ultrasound.(Specificity of clinical examination)Patients with positive (B5b) for staging following MDM decision.

Assessment of M5 abnormalities in women undergoing yearly mammograms surveillance(NOT NBSS patients)patients where MRI is desirable but contraindicated.

How we do it :The machine is adapted to take 2 consecutive exposures under the same compression: we start with the unaffected breast.

• Low energy image

• High energy image

Administer intravenous iodine contrast agent, exactly the same as CT exams: 1.5ml / kg; 3 ml sec. Images are automatically processed and displayed on the monitor.

Mammography Standards Respected – Dose < guidelinesDedicated quality control protocol using the usual FFDM phantom

DICOM compatible

Published data on CESM examinations with comparison to US,Mg,MRI for detection of breast cancer, lesion size estimation &preoperative staging.

Current results suggests similar to breast MRI

Dromain at el,EUR Radiology 2011

CESM useful in assessment of extent of disease, allowing a better evaluation of lesion size& detection of multifocal disease than MG alone or combined with US.

CESM provides more accurate lesion detection and size assessment than digital mammography and not inferior to MRI.

Fallenberg at el Eur Radiology September 2013

Lesion size CESM vs histopathology

1. Prospective data from 1.1.2015 –7.05.20162. Number CESM - 117 in 116 patients.3. All patients where P4-5symptomatic and

referred by surgeons.4. All patients had MDT discussions.5. All CESMs were double reported as part of

learning process for the radiologists.

Methods and materials

CESM data analysis of CESM cases performed at Kettering 1/2015 - 17.05/2016

117

Number of cases for assessing Neoadjuvant chemo response ( Claustrophobia after MRI)

2 ( 1 x patient)

Number of cases where consent with-held to use images and data

3

Number of patients who had CESM but where found to be benign (clinically P4)

3

Number of patients who underwent Neoadjuvant chemotherapy

17

Number of patients missing data (relocation) 6Number of CESM of patients awaiting surgery 15

Number of patients who had CESM but diagnosed with Non-breast neoplasm and had NO breast surgery

1

Number of patients who have undergone CESM and surgery

42

Number of patients who have undergone CESM and MRI and Surgery (NICE guidance and MDM)

29

CESM was as sensitive as MRI in all 28 patients 96%

One false negative results for both modalities (8 mm Low grade IDC)

CESM was more accurate than MRI in 8 patients Neither CESM nor MRI predict accurate tumour

size in lobular cancers and in cases of B5b and B5a admixture.

Results I: CESM vs MRI group 29 patients

CESM Sensitivity 97 % 1 false negative case Very good correlation between CESM and

Histology in invasive disease. Less accurate when DCIS admixed( 4 patients

with discrepancies in size up to 15 mm max.) CESM had Impact on 30% of cancer patient

management in our study.

Results II: CESM vs Surgery 42 patients

Dromain et al 120 patients:

Compared CESM +MG Vs.MG alone or MG+US Enahncement :92 % cancers

Conclusion ADVANTAGES DISADVANTAGES

High sensitivity for invasive disease comparable to MRI

But if<100 MRI p.a. = KGH not eligible for FH screening

Patient comfort Possibility of Iodine allergyLow cost No coding yet – inadequate payment*Radiographers led model Cannulation & resuscitation re-trainingQuick learning curve Not for breast implantsEasy correlations with images

Low sensitivity for B5a and lobular BCa

Familiar images for breast surgeons to look at

X-Ray radiation

Both breasts investigated No CESM guided interventions*

CESM CASES

Case 1 - adjunct to inconclusive mammo

Images courtesy of Institut Gustave Roussy, Villejuif, France

L

RCC 2 minRMLO 2 minTrue negative result - biopsy : normal parenchyma19 month follow up

Case 2

Case 3

Case 4

Case 4

Case5

Interesting educational journey Great team effort Two useful modalities implemented Tomo- now approved for screening

assessment CESM use for staging and possibly for

monitoring Chemo response KGH -reference site in UK for other users

Conclusion

Thank you

Sana.Pascaline@kgh.nhs.uk