The Role Of Imaging And Interventional Radiology In Breast Diseases

The Role of Imaging and Interventional Radiology in Breast Diseases Sanjay Sharma

MD, DNB, FRCR (Lon) Associate Professor

Radio-diagnosis

AIIMS, New Delhi

Breast Cancer #

1 female cancer in world  # 1 female cancer in Indian metros Mammography is the only standard and proved cancer screening technique Reduces mortality by 20-35%* *JAMA2005;293:1245-56 (Meta analysis)

Breast Imaging Modalities  Mammography

is the primary modality  Complimentary modalities – – –

Ultrasound MRI Scintimammography, PET

Mammography  Radiography

of breast  Modified to evaluate low density soft tissues with high contrast and spatial resolution – –

Low energy x-rays High resolution films Resolution of mammography is several times better than any other imaging modality

BIRADS Grades Grade Interpretation

Managemant

0

Incomplete evaluation

Complete it

1

Normal

None

2

Benign

None

3

Probably benign (<2%)

Short follow-up

4

Suspicious/ indeterminate Biopsy

5

Highly suspicious (>95%)

Biopsy

BIRADS Grades: Masses 2

3

4

5

BIRADS Grades: Calcifications 2

3

4

5

Digital Mammography

Digital Mammography: Requirements  High

resolution flat panel detectors  Powerful workstation –

Up to 27 mega pixels per image!

 High

resolution, high brightness monitors

Digital Mammography: Advantages  Post –

processing

e.g. zoom, pan, windowing, contrast, edge

 No

artifacts  No under/ overexposed images  Digital storage and communication –

PACS/ Teleradiology

Digital Mammography: Disadvantages  High

cost  Inferior spatial resolution -5-10 lp/mm with FFDM -(versus 12-15 lp/mm with conventional FSM)

 Films

display more gray shades than monitor

Digital Mammography 

Should we go digital?? -Digital mammography is still in infancy –



Accuracy is comparable to film-screen mammography*

Potentials of new applications are already demonstrated (not possible with FSM)

*N Engl J Med 2005;353:1773-83

Computer Aided Detection (CAD)  Help

inexperienced radiologists  Inexpensive alternative to second radiologist for ‘double reading’ – –

Sensitivity for missed cancers: CAD 95%* Vs ‘double reading’ by radiologists 64% *AJR 2007;188:377-84

 Cancer

detection rate increased by > 20%# AJR 2003;181:687-93

#

Tomosynthesis 

 

Low dose exposures at different angles Produces tomograms Useful in dense breasts

Ductography   

Single duct discharge Uncommonly performed US and MRI are also useful

Breast US: Indications  Evaluation

of clinical or mammographic abnormalities – – –

Differentiation of cystic Vs solid mass Asymmetric densities Dense breasts

 Young,

lactating, pregnant women  Implants  Interventions

Cysts  

Simple cysts Complex cysts

US diagnosis of simple cyst is important as it does not require biopsy, treatment or follow-up

Masses 

Benign – – –



Round, oval Well defined walls Distal enhancement

Malignant – – –

Irregular Poorly defined walls Distal shadowing

Breast MRI  Recently – – – –

in focus

Dedicated breast coils Standardized protocols and ACR reporting lexicon MR compatible needles Enough literature

 Sensitivity

90-100%, Specificity 50-70%* for breast cancer detection *Radiol Clin N Am 2004;42:919-34

Breast MRI: Indications 

Before diagnosis – –



After diagnosis – –



Equivocal mammogram Screening modality in high risk women Preoperative staging Assess response to chemotherapy

After treatment – –

FU Scar Vs recurrence

Not to be used as an alternative to mammography/ biopsy

Breast MRI: Cancers 

Morphology similar to mammography

Dynamic CE MRI of Breast

plain 0 min 1 min 2 min 5 min delaye d

Breast MRI: High PPV for cancer Ring Enhancement

Heterogeneous internal enhancement

Ductal distribution

MR Screening  BRCA

1, BRCA 2 mutations  MRI is the only screening tool in these women* – –

MRI sensitivity 94%# (CBE 50%, mammography 59%, USG 65%)

*Lancet 2005;365:1769-78 # Radiology 2007: epub

PET 

Most accurate* – –

 

Sensitivity 88% (25% for <1cm tumors) Specificity 80%

Single stop shop for both local and complete body assessment Dedicated PET mammography units# are being developed –

Detection of small tumors *Acad Radiol 2002;9:773-83 (meta analysis) # Radiology 2005;234:527-34

Molecular Imaging With PET  16 –

alpha fluoro estradiol In vivo ER receptor analysis

 F18 –

tamoxifen

Detection & response assessment of ER+ metastases

 Cu64 –

monoclonal antibodies

Tumor grade and malignant potential

Image Guided Breast Biopsy  Guidance – – –

US Stereotactic (mammography) MRI

 Core – –

biopsy more accurate than FNAC*

FNAC sensitivity 77% Core biopsy sensitivity 98%, no false + *Acad Radiol 2004;11:293-308

US Guided Core Biopsy

Stereotactic Biopsy 



Preferred technique for mammography detected cancers Type of units – –

Add-on erect unit Dedicated prone table

Directional Vacuum Assisted Breast Biopsy (DVAB)  Mammotome®  Multiple,

large cores with single insertion

Mammotome® Biopsy  



8-11 G Needles 5 fold more tissue per core (18 Vs 98 mg)* Better concordance (100%#) with surgical biopsy than FNAC/ trucut Bx

Mammotome cores

Tru cut cores *Radiology 1997;205:203-08 # AIIMS study, continuing

Hook Wire Localization  Pre

operative procedure for open surgical biopsy or therapeutic lumpectomy  Aim – – –

Guides surgeon to accurately reach and remove the non-palpable lesion Accurate pathological sampling Minimize surrounding tissue removal

 Mammography,

US or MR guidance

Planning of Breast Conservation Surgery 

Imaging is required in a diagnosed case – – –



Extent of the tumour Additional lesions Baseline

Mammography is the primary modality

Breast MRI: Preoperative Staging 

 

Accurate assessment of size & local spread of index tumor Detects additional foci in 41% patients* Changes management in 26% patients# *AJR 2005;184:868-77 # Cancer 2003;98:468-73

Residual Tumor  





After lump excision Positive margins after BCS Mammography and USG are difficult to perform and interpret MRI is most accurate* AJR 2004;182:473-80

*

Follow up Imaging  Seroma

– round, oval density  USG most useful in immediate post-op

Follow up Imaging  Mammogram

six months after BCS and annually thereafter  Post RT changes – – –

Increased breast density Skin thickening Thickening of trabeculi

Recurrence 

Mammography is usually sufficient – – –



New opacity Increased density/ size of scar New suspicious calcification

MRI/ PET in equivocal cases

Recurrence 

PET: Highest sensitivity –

Sensitivity- local 90%, distant 100% *J Cancer Res Clin Oncol 2003;129:147-53

Neo-adjuvant Chemotherapy  Assess – –

response

Mammography/ MRI PET is most accurate

 Pre-op

hook wire localization, if lesion becomes non palpable

Radio-frequency Ablation  Minimally

invasive alternative to surgery in small breast cancers  Feasibility studies have shown complete tumor ablation with adequate margins in 95-100% Radiology 2004;231:215-24 J Surg Oncol 2006;93:120-28 AIIMS study (continuing,unpublished)

Radio-frequency Ablation 



Randomized trials have been planned Combination of RFA+SN mapping may offer minimally invasive alternative to conventional surgery

In India  Screening

mammography is a distant dream

However,  Diagnostic and interventional breast radiology of symptomatic breast is no less important  We must tailor our approach to new developments in the breast radiology

Thank You