This document discusses various breast imaging modalities for screening and diagnosis of breast cancer. It provides an overview of mammography, digital breast tomosynthesis, ultrasound, MRI, and molecular breast imaging. Mammography remains the primary screening tool, though its sensitivity decreases with breast density. Digital breast tomosynthesis has been shown to improve cancer detection rates compared to digital mammography alone. Ultrasound is useful as an adjunct but has high false positive rates for screening. MRI is recommended for screening high risk patients due to its high sensitivity. Molecular breast imaging is a potential adjunct screening tool for dense breasts that may help increase cancer detection over mammography alone.

1. Pamela J DiPiro, MD
Clinical Director of CT and Breast Imager
Dana-Farber Cancer Institute
Imaging after Breast Cancer

2. Conflict of Interest Disclosure
I have no financial relationships
with a commercial entity
producing healthcare-related
products and/or services.
Pamela J. DiPiro, MD

3. Breast Imaging
• Mammography
• Tomosynthesis (3-D mammo)
• Ultrasound
• Magnetic Resonance Imaging (MRI)
• Molecular Breast Imaging (MBI)

4. Mammography
• 2005 (DMIST) Digital Mammography
Imaging Screening Trial
– digital vs film
• women < 50 yrs
• heterogeneous or extremely dense
• pre- or perimenopausal
• 2D imaging
– 2 MLO, 2 CC
– +/- magnification, spot, exaggerated views

5. 45 yo female 7 yrs after lumpectomy and radiation. Asymptomatic.

6. 51 yo female 3 yrs post lumpectomy and radiation. Asymptomatic.

7. 2014 2015 2016

8. Mammography
• Breast screening workhorse
• Overall sensitivity =78%*
• Varies with breast density
• As high as 87% in fatty breasts**
• As low as 30% in dense breasts***
*National Cancer Institute website
**Carney PA. Ann Intern Med 2003
*** Mandelson MT et al. J Natl Cancer Inst 2000

9. A B C D

10. Digital Breast Tomosynthesis
(DBT)
• (3-D) imaging technology that acquires
images of a stationary compressed
breast at multiple angles during a short
scan.
• Individual images are reconstructed into
series of thin high-resolution slices.
• Can reduce or eliminate tissue overlap
effect

11. From Radiol Clin North Am, Sept 2010

13. European Prospective Trials
• Oslo - Norway
• STORM - Italy
• Malmö – Sweden
• Equal or better accuracy in cancer
detection with breast tomosynthesis (DBT)
compared to digital mammography (2D)

14. Tomosynthesis Breast Screening
Study * (Oslo, Norway)
• 25,547 women (50-69 yo), biennial
• 2D vs 2D+DBT
• Improved cancer detection rate:
– 6.4/1000 (63%) – 2D
– 8.3/1000 (82%) – 2D + DBT
– 1.9 additional cancers/1000
*Skaane et al RSNA 2014

15. STORM trial
Screening with Tomo OR standard Mammo
• 7292 women (> 48 yo), biennial
• 2D vs 2D+DBT
• Improved cancer detection rate:
– 5.3/1000 – 2D
– 8.1/1000 – 2D + DBT
– 2.8 additional cancers/1000
– 34% increased detection
*Ciatto et al 2013, Lancet Oncol 2013

16. Tomosynthesis in US
• No large prospective studies
• Not systematically evaluated (DMIST)
• Driven by lay press
• Multiple observational studies
• Various roles of DBT
– Screening
– Diagnostic
– Callbacks (+/- spot compression)

17. Friedewald et al. JAMA 2014
• Retrospective analysis of 13 acad and nonacad
breast ctrs
• Total >450,000 mammos
• 2D vs 2D+DBT
• Cancer detection increased by 1.2/1000
• Decreased callbacks by 16/1000 (15%)

18. Indications for DBT
• Screening (esp Baseline*)
–Decreased recall rate
–Increased sensitivity
• Diagnostic workup (if BL or request)
• Callbacks (not calcifications-mags)**
*McDonald ES et al AJR 2015
**Zuley et al. Radiology 2013, Peppard HR. Radiographics 2015

20. 2012 2011 2008

23. 62 yo woman w skin dimpling and palpable mass in right lower mid-inner breast
US(-), MRI bx – radial scar

24. Tomosynthesis Limitations
• Longer acquisition time
• Longer interpretation time (at least 2x)
• Greater need for computer power and storage
• Slightly more costly
• Higher radiation dose (synthesized image*)
• May obscure margins of circumscribed masses
• Detecting more radial scars

25. Tomosynthesis Benefits
• Decreased recall rate
• Improved cancer detection 1/1000-2/1000
– spiculated masses
– architectural distortion
– small, node(-) invasive cancers

26. Ultrasound
• Important adjunct to mammography
• Indications:
– Evaluate palpable lesion
– Characterize mammographic finding
– Follow response to neoadjuvant
chemotherapy
– Attempt to isolate MRI findings
– Biopsy/aspiration guidance
– ? Role for dense breast screening

27. 32 yo female with palpable lump in left breast

29. Simple cyst

30. 32 yo female noted discomfort and “fullness” at lumpectomy site.

31. Seroma = post-operative fluid collection

32. 42 yo female, 1 yr post lumpectomy and radiation with
new palpable lump near scar. Mammogram 2 months
earlier was (-).

33. Courtesy of Dr. Sughra Raza

34. 2011 2013 2015

35. 2 years after treatment, new palpable area of concern
Courtesy of Dr. Sona Chikamarne

36. Ultrasound Screening
• Controversial
• Non-specific
• Operator-dependent
• Time-consuming
• Poor visualization of calcifications
• Utilized in Europe, was less popular in
US, until recently

37. Dense Breast Tissue
• Approx 40% of women 40-74 yrs
• Category C, D
• Confers slightly increased cancer risk
• Makes cancers harder to detect via
mammography (masks lesions)*

38. A B C D

39. Dense Breast Legislation
• 1st CT in 2009
• 28 states* (discussion of federal legislation)
• MA - passed legislation 1/1/2015
• Mandates informing patient of their breast
density
• Variable approaches by state re: disclosure
and recommendation for supplemental
imaging
*7 additional states in process

40. Discussions in MA
• No immediate test recommended
• MD and patient should discuss risk and
further evaluation
• Use some type of model to calculate risk
• Awareness of U/S thru popular press

41. ACRIN 6666 (ACR Imaging Network)
• Prospective trial, April 2004 – Feb 2006
• 2809 women
• at least heterogeneous dense + high risk
• 21 sites, mammo + U/S (MD-performed)
• MD masked to results of other studies
Conclusions*:
• U/S yielded additional 4.2 cancers/1000
• Substantial increase # of false (+)
*JAMA 2008. Berg et al.

42. Multiple additional studies
• Different populations, including dense
screening
• Increased cancer detection (3-4/1000)
• Small, invasive cancers, most node (-)
• Low PPV for biopsies

43. Screening Whole Breast
Ultrasound technical limitations
• Long scanning time (19 min –
ACRIN 6666)
• Training
• Expertise
• MD vs tech scan

44. Automated Breast Ultrasound
• 1st FDA approved automated breast u/s
(9/18/2012)
• 60-70 sec acquisition; 10-15 min total
• 3D U/S images (3 planes)
• Intended use:
• dense breasts
• neg/benign mammogram
• no prior invasive procedures

46. Ultrasound Overview
• Important adjunct to mammo
– Characterizing lesions (palpable, imaged)
– Guidance for biopsies/aspirations
– Following response to chemotherapy
• Screening
– 3-4/1000 additional cancers
– High false (+)
– High risk women where MRI is unavailable*
– Controversial for women with dense breasts as
only risk factor*
*Sickles EA. Rad Clin North Am 2010

47. Magnetic Resonance Imaging
(MRI)
• Evolving role in screening and evaluation of
breast cancer
• Variably used
• ACR Practice Guidelines based on multiple
studies from different institutions

48. ACR Practice Parameters for Performance
of Contrast Enhanced Breast MRI
• Screening
– High risk
– Contralateral breast in newly dx’d malignancy (3.1-5%)*
– Breast augmentation
• Extent of disease
– IDC/DCIS (multifocality/multicentricity)
– Invasion deep to fascia
– Post-lumpectomy with (+) margins
– Neoadjuvant chemotherapy
• Additional evaluation of clinical/imaging findings
– Recurrence of breast cancer
– Met cancer of unknown primary (suspect breast)
– Lesion characterization
– Post-op tissue reconstruction with suspected recurrence
*Liberman AJR 2003, Lehman NEJM 2007

49. ACS Guidelines for breast screening with
MRI as an adjunct to mammography*
• Based on nonrandomized trials/observational studies, annual
screening recommended:
» BRCA mutations (and untested 1st degree relatives)
» Patients with lifetime risk > 20-25%
• Based on expert consensus and evidence of lifetime risk, annual
screening recommended:
» Li-Fraumeni Sx (and 1st degree relatives)
» Cowden and Bannayan-Riley-Ruvalcaba Sx (PTEN gene
mutations)
• Insufficient evidence to recommend for or against annual screening
(decide on case by case basis):
» Patients with lifetime risk < 15-20%
» h/o LCIS, ALH, ADH
» Heterogeneously or extremely dense breasts
» Personal h/o breast cancer (including DCIS)
*Saslow D et al. CA Cancer Clin 2007

50. MRI screening in high risk patients
• BRCA1 and BRCA2 mutations
• Li-Fraumeni and PTEN gene
mutations
• Strong family history
• Prior mantle irradiation for HD

51. High Risk Breast Screening
• Annual mammogram
• Annual MRI
• Typically, stagger 6 mos apart
• Can get same time, annually

52. 54 yo BRCA1 mutation carrier s/p left lumpectomy and
radiation for breast cancer and benign right breast biopsy –
screening MRI
Right Breast

53. Ultrasound (-) Pathology: DCIS

54. Breast MRI sensitivity for cancer
detection
• Range: 71-100% in screening MRI studies*
• As supplement to mammography: 80-
100% sensitivity**
• Sensitivity is lower for in situ than invasive
cancer
•*Mahoney MC. Magn Reson Imaging Clin N Am 2013
•** Warner E. Ann Intern Med 2008

55. MRI
• Increased sensitivity
• Variable specificity
• However- IS used to screen in high
risk populations

56. Molecular Breast Imaging (MBI)
• 99mTc-sestamibi mammoscintigraphy
• MBI, though less widespread, has been used
for years at sev’l centers
• New, dual-head gamma imaging camera with
reported increased sensitivity/specificity and
lower dose when compared with earlier
systems (sens/spec 96.4% 59.5%)*
• Potential adjunct breast screening modality
*Radiology 2008. Brem et al

57. Combined MBI and FFDM
1585 women, dense breasts
2D vs 2D + MBI
• Yield/1000: 2D 3.2, 2D + MBI 12.0
• Sensitivity: 2D 24%, 2D + MBI 91%
• Specificity: 2D 89%, 2D + MBI 83%
• PPV3: 2D 25%, 2D + MBI 28%
Conclusion:
Addition of MBI to screening mammo yielded
supplemental cancer detection rate of 8.8/1000
AJR 2015, Rhodes et al

58. Courtesy of Robin Shermis,MD, ProMedica Toledo Hospital, Toledo, OH
63 year old woman with prior history of breast cancer
Mammogram

60. MBI
Advantages: Inexpensive
Accessible: Tc99m-sestamibi
Improved sens/equiv spec
Disadvantages: No biopsy device yet
Effective dose equivalent of
2.7 mSv to whole body

61. Screening
• Mammography- imperfect, but remains
screening tool for gen’l population
• Tomosynthesis- slight increase in detection,
though increased time +/- radiation
• Ultrasound- excellent adjunct, but false (+)
quite high for screening
• MRI- screening high risk patients (where cost
and false + acceptable)
• MBI- potential adjunct screening in dense
breasts (decrease radiation)