Breast Imaging and Interventions Update
18th Annual Breast Imaging and Interventions Update
Hotel Del Coronado • Coronado, California
Sunday, October 23, 2016 TABLE OF CONTENTS
Sunday, October 23, 2016 Ductography: Techniques and Findings (Haydee Ojeda-Fournier, M.D.)...... 189 Controversies in Management of Core Biopsy Showing “High Risk” Lesions (R. James Brenner, M.D., JD, FACR, FCLM)...... 205 Preventable Causes of False Negatives (R. James Brenner, M.D., JD, FACR, FCLM)...... 223 Controversies in Use of MRI for Staging and Extent of Disease (R. James Brenner, M.D., JD, FACR, FCLM)...... 255 US Case Review (Mohammad Eghtedari, M.D., Ph.D.)...... 269 189 190 Outline
• Clinical features of nipple discharge Ductography: • Imaging of nipple discharge • Ductography techniques Techniques and Findings • Ductography findings Haydee Ojeda-Fournier, MD • Algorithm for management of patients with nipple Associate Professor of Clinical Radiology discharge UC San Diego Moores Cancer Center La Jolla, California [email protected]
Introduction Incidence
• Nipple discharge is a cause of patient anxiety • 3-9% of patients seen in breast clinic • Most frequently benign • Incidence of nipple discharge in breast cancer is • Evaluated by clinical exam, mammogram, US 5-12% and ductography – US and ductography are helpful only when positive • Expressed, multiple, bilateral discharge does not warrant evaluation • Gold standard is major duct excision
Clinical characteristics of nipple Causes of nipple discharge discharge
Benign High risk Malignant Ductal ectasia Papilloma Ductal Carcinoma in Situ Benign Suspicious (DCIS) Cysts Papillomatosis Invasive ductal Bilateral Unilateral carcinoma (IDC) Central causes/ Atypical ductal Non-spontaneous Spontaneous* physiologic hyperplasia (ADH) Multiple ducts Single duct Lactation Mastitis Non-bloody Bloody or clear** Gynecomastia
Medications *Most important feature Nipple adenoma **Any appearance
191 Cytology Patient preparation
• Sensitivity of cytology is low • Ask the patient not to elicit discharge prior to • Negative cytology does not exclude pathology procedure • Only positive cytology results have value • Explain procedure to relieve anxiety • Atypical cells can be misleading – Annoying probing – Feeling of fullness • Position as comfortable as possible • Cytology is unreliable and not recommended • Keep room and patient warm – May need warm compresses
Equipment
• Adequate lighting • Magnification glasses (preferred) or lens • 30-gauge blunt-tip sialography needle with attached tubing • Contrast and methylene blue • Skin prep • Gauze • Set up for needle localization • Topical anesthesia or dilators are not needed for this procedure
Procedure step
1. Informed consent 2. Time out 3. Prepare cannula and contrast 4. Elicit discharge 5. Probe discharging duct 6. Cannula will fall painlessly in duct 7. Gently administer contrast until patient feels fullness 8. Removal of cannula v. tape cannula to skin 9. Magnification images subareolar region in the CC and lateral projection
192 Procedure contraindications
• Mastitis • Abscess
Procedure complications
• Unusual – Extravasation – Duct perforation – Fistula – Opacification of lymphatic channels • No reported contrast reactions
• Unable to cannulate – Can try warm compresses
193 Pitfall: Air bubble
Ductography: Normal ducts
• Varies with age • Variation in duct width, branching pattern, distribution • Contrast blush: Filling of lobular unit
Common ductographic findings
• Complete ductal obstruction • Multiple irregular filling defects in the non-dilated peripheral ducts • Ductal wall irregularities • Ductal displacement • Microcalcifications or mass adjacent to abnormal duct
194 Ductography: Ductal ectasia Ductal ectasia
• Dilated duct • Can be seen on all imaging modalities as • Limited branching subareolar ductal dilation • Limited parenchymal distribution • Presents with nipple discharge, retraction, mass or pain • Evaluate for internal debris or filling defects which are suspicious and may require additional evaluation
195 Ductography: Fibrocystic changes
• Normal duct width and branching pattern • Filling of cysts • Dilation of the terminal ductal lobular unit • Can communicate with the ductal system resulting in nipple discharge • Simple cysts are benign and require no further evaluation
196 Ductography: Papilloma Solitary papilloma
• Clinical presentation: • Intraductal filling defect – Spontaneous clear or bloody • Complete ductal obstruction nipple discharge • Ductal expansion with associated distortion • Most common intraductal mass • Histologically seen as papillary • Irregularity of ductal wall fronds attached to the duct wall via a fibro-vascular stalk Patient presenting with spontaneous drop of blood in the upper outer quadrant of the nipple.
Solitary papilloma
• Tends to be central • Usually resected as the papilloma may contain atypia or cancerous components • Both ductograms and ultrasound can show intraluminal masses (arrows) • The mass may contain cystic components
197 Papillomatosis Radial scar
• 5 or more papillomas in a breast segment • More frequently associated with atypia, DCIS, or invasive carcinoma • Tend to be in the peripheral ducts or terminal lobules, and is usually bilateral Only three filling defects were • Imaging appearance is also identified by ductogram on this similar to solitary papillomas patient with pathology proven unless the mass has undergone papillomatosis. malignant transformation
Sclerosing papillary lesion
198 Ductography: Carcinoma
• Complete duct obstruction • Filling defect • Irregularity of ductal wall • Displacement of ducts
Wire localization after ductogram
• Less extensive surgery • Improved surgical localization • Patients are scheduled for ductography after surgical consultation • A standard needle localization is performed • If ductogram is normal, a major duct excision may be performed
199 Patient scheduled for ductography only
• Options include: – US evaluation and core biopsy while lesion is visible – Stereotactic biopsy – Clip placement
Clip placement after ductogram
US guided biopsy after ductogram
200 Stereotactic biopsy after ductogram
• May be difficult to spontaneously schedule • Prone position may lead to discharge of contrast • Subareolar location is challenging to stereo
Disadvantages Nipple discharge
• Time consuming Unilateral Bloody or Bilateral Multiple • Requires patience (radiologist and patient) Clear ducts • Contraindicated in patients with infection
• Distal lesions may be missed High risk Mammogram and No further patient Ultrasound imaging
Breast MR Negative Positive finding
Clinical Image guided evaluation and biopsy Ductogram
Summary Summary cont.
• Nipple discharge is commonly encountered in • Any suspicious imaging findings must be breast imaging centers biopsied • Quality of symptoms including unilateral, • Cytology can be misleading spontaneous discharge from a single duct raises • Ductogram goals: clinical suspicion – Diagnosis of the underlying conditions, the definition • Mammography and ultrasound are good starting of disease extent, and guidance for surgical excision points for evaluation • Suspicious clinical findings without imaging • MRI can be considered in high risk patients, or for additional problem solving correlate warrant surgical consultation
201 Thank you!
202 203 204 205 206 Controversies in Percutaneous Breast Atypical: more cohesive but large Biopsy MALIGNANT N/C ratio
R. James Brenner, M.D., FACR Director, Breast Imaging, Bay Imaging Consultants at the Carol Ann Read Breast Center Professor of Radiology University of California, San Francisco
Fibroadenoma
How much tissue per sample:automated
• Spring loaded devices: 14 gauge (Rad 1995; 197:739) – 57 lesions (surg proof);26 cancers (variable number of samples!) – sensitivity: 100% (14G), 92% (16G), 65% (18G) # OF SAMPLES – Brenner et al (Rad 2001;218:866):N=5 for masses 98% accuracy; more for calc, arch dist – Fishman et al (Rad 2003;226:779-82): N=4 (masses),sink,whole
R. James Brenner, MD R. James Brenner, MD
How much tissue to remove: vacuum No Calcification on Specimen (Rad 2006; 239:61-70)
Jackman (Rad 2006; 239:61-70) • Retrospective review of 1701 calc stereo cases Optimal: 12-18 samples (lowest nonretrieval rate) • Rates difference for needles (14G auto:16%; 14G vac: 4%; 11Gvac 1%): non retrieval: 3/40 lesions = CA by re-bx or f/u mean 5+ yrs_ – 14G auto: 30/182; 14G vac: 4/96; 11G vac: 19/1423 • 56 cases with no calc: repeat bx =17, f/u mean 5+yr Philpotts, et al (AJR 2000;175:1047-1050) 158 cancers – 3 malignancies 12 samples per case, 11G • NB:histolog calc NOT concordant (<0.1 mm) UNDERESTIMATES: 9.5% (15/158): mass: 1.6%, calc 16.3% (espec if whole lesion not removed) ADH TO • Optimum # samples: 12-18 MALIGNANT: N=6 (5 DCIS, 1 IDC) DCIS to IDC : n=9
R. James Brenner, MD R. James Brenner, MD
207 Defining the issue of “high risk” Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • NOT necessarily an issue of global risk • Lobular Carcinoma In Situ assessment • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • RATHER: Is there a sufficiently high likelihood • Flat Epithelial Atypia that the specific anatomic area in question was “undersampled” with percutaneous biopsy Phyllodes, Focal Fibrosis, PASH, Sclerosing Adenosis, Columnar alteration ( Mucocele)
R. James Brenner, MD R. James Brenner, MD
Bx = fa
R CC L YR 1 R MLO L YR 2
Enlarge excise = phyllodes R. James Brenner, MD R. James Brenner, MD
Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat epithelial atypia Phyllodes, Focal Fibrosis, PASH,Sclerosing Adenosis, Columnar alteration (mucocele)
R. James Brenner, MD R. James Brenner, MD
208 Fibrous nodules: 38/853 (4%) with surg on 13 and repeat core on 3) R. James Brenner, MD Harvey SC, et al. Radiology 1999:211:535-40) R. James Brenner, MD
Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat epithelial atypia Phyllodes, Focal Fibrosis, PASH, Sclerosing Adenosis, Columnar alteration (mucocele) Excision post core: Fibrosis
R. James Brenner, MD R. James Brenner, MD
MLO CC SPOT MAG CC
Pseudo- Angiomatous PASH Stromal Hyperplasia
MLO CC R. James Brenner, MD R. James Brenner, MD
209 US
YR 1 R CC L R MLO L
CC YR MLO 2
Pseudoangiomatous Stromal Hyperplasia Post clip
R. James Brenner, MD R. James Brenner, MD
Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat epithelial atypia ______Phyllodes,Focal Fibrosis, PASH, Sclerosing Adenosis, CC MLO Columnar alteration (mucocele) Sclerosing Adenosis R. James Brenner, MD R. James Brenner, MD
Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat epithelial atypia ______Phyllodes,, Focal Fibrosis PASH, Sclerosing Adenosis Columnar alteration (mucocele)
Sclerosing adenosis R. James Brenner, MD R. James Brenner, MD
210 Apocrine Cyst=Apocrine Metaplasia cluster of cysts “spokeswheel septae” Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar IF associated • Flat epithelial atypia With clustered ______Calc: possible Phyllodes,, Focal Fibrosis PASH, Sclerosing Adenosis Mucocele Columnar alteration (mucocele)
R. James Brenner, MD (AJR 2011; 196:1424) R. James Brenner, MD
Two Lobules with columnar change: one low-grade, one high-grade
Lobular columnar hyperplasia-note apical snouts
R. James Brenner, MD R. James Brenner, MD
Columnar Cell Alteration Potential Tissue Sampling Errors
• Columnar cell change--? Leave alone • Atypical Ductal Hyperplasia (ADH) • Columnar cell hyperplasia (CCH)--?leave alone • Atypical Lobular Hyperplasia/ALH • CCH with atypia--?excise • Lobular Carcinoma In Situ • CCH with ADH—EXCISE • Discreet Papillary lesions (r/o papillomatosis) • Flat epithelial atypia—EXCISE • Radial Scar • NB: Some lump everything with hyperplasia into FEA • Flat epithelial atypia ______• ??increased incidence of AH in these patients Phyllodes,, Focal Fibrosis PASH, Sclerosing Adenosis • (Cancer 2008; 113:2415-21) Columnar alteration (mucocele)
R. James Brenner, MD R. James Brenner, MD
211 Columnar Cell Alteration
• Columnar cell change--? Leave alone • Columnar cell hyperplasia (CCH)--?leave alone • CCH with atypia--?excise • CCH with ADH—EXCISE • Flat epithelial atypia—EXCISE • NB: Some lump everything with hyperplasia into FEA
• increased incidence of AH in these patients • (Cancer 2008; 113:2415-21)
R. James Brenner, MD
Flat Epithelial Atypia Potential Tissue Sampling Errors
• Range up upstaging: 0-21%: average: 8% • Atypical Ductal Hyperplasia (ADH) • Without other atypia: upstage 0-3.2% • Atypical Lobular Hyperplasia/ALH – (Am J Surg Path 2009;33:1078; Virrch Arch 2012; 461:419) • Lobular Carcinoma In Situ • Longest follow up: 6.2 years mean (1-11) • Discreet Papillary lesions (r/o papillomatosis) – (Virchows Arch 2007; 451:883-9): study from 1990s • Radial Scar – 63/1751 (3.6%) • Flat epithelial atypia – 9/63 (14.3) malig, but only 7 ipsilateral (11%) with mean Phyllodes, Focal Fibrosis (PASH), Sclerosing Adenosis, follow up of 3.7 yrs columnar alteration (mucocele) • Of these, 2 had another bx showing ADH and FEA
R. James Brenner, mD R. James Brenner, MD
212 R. James Brenner, MD R. James Brenner, MD
ADH—Can surgery be avoided? ADH: A non obligate precursor of Low Grade DCIS • Rad 2002; 224:548-54: 104 cases ADH: no mammo • Distinguish polyclonal usual hyperplasia from features to distinguish DCIS from ADH clonal low grade DCIS • No resid calcifications: 1/65 had Ca at f/u (none of 26 at surg): AJR 2011; 197; 1012-1018 • ADH shares 16q genetic loss lie low grade DCIS • 47 core biopsy cases: excision: 15 DCIS; 2 IDC: none • (16q deletion in only 30% of high grade (J Path had malignancy if 2005; 205:248) (“ductal intraepithelial neoplasia) • a. not micropapillary • Morphology is similar—rigidity of the arches- • b. 4 or fewer TDLUs involved with ADH at core Roman arches—vs loose spaces • (Am J Surg Path 2002; 25:1017) • Defn: to call DCIS, area must be >1.9 mm
R. James Brenner, MD R. James Brenner, MD
Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat epithelial atypia Phyllodes, Focal Fibrosis (PASH), Sclerosing Adenosis, columnar alteration (mucocele)
R. James Brenner, MD R. James Brenner, MD
213 ALH/LCIS-Small series reports
• Study # Pts Upgrade(inv/dcis) Issues Ref
• Foster 35 6 (17%) (4 DCIS) 2 sites Rad 2004 • Inst A:12 + stereo cores; 5+ Us cores Inst B: 6+ stereo cores; • 3+ US cores neoplasia: “most with 11 G and large number”
• Lieberman 14 3 (0-26%)–confusion w ADH/DCIS AJR 1999 • Berg 11 1 (9%)DCIS Rad:2001 • Philpotts 5 1(20%) DCIS Rad: 2000 E-CAHDHERIN STAIN FOR DUCTAL CELLS • G-Smith 2 2(40%) ILC necrosis AJR: 2001 R. James Brenner, MD R. James Brenner, MD
ALH/LCIS: CLINICAL 11G evaluation Lobular Neoplasia IMPLICATIONS (AJR 2006; 187:949-954) • LCIS to invasive cancer: • 27 pts with LN (no ADH, DCIS, or invasive Ca) – 48/10,542 bxs: 17% risk of invasive ca (19-25 yr f/u) – (Page et al, Hum path 1991; 22:1232-39) • Mean specimen: 13 – Goldstein (Ca 2001; 92:738): CNB LN w 21 year f/u: 10/20yr: 7.8%/14.5% • CA in 5/27 lesions (19%), 20 surg (10/12 LCIS), • ALH: 3x more likely to develop cancer in the SAME breast o/w mean f/u 52 mos ????”field defect problem” • ReAnalysis: 2 pleomorphic, one arch – -not necessarily a local issue BUT distortion=3/27 lesions = 11% Conclusion; intermediate risk of local disease vs general risk (Page et al Lancet 2003;360”:125-9) • Key notion: Different “grades of LCIS”
R. James Brenner, MD R. James Brenner, MD
Lobular Neoplasia Lobular neoplasia: problem with Nagi, et al. Cancer 2009; 112:2152-8; Hwang. Mod Pathol 2008; 21:1208-16: 333 discordance and sampling? 98 cases (91 calc, 7 mass) – Brem, AJR 2008 ; 190:(637-41): 28% upgrade, different • 45 excised: definitions of discordance – 93% (n=42)—only LN – Destounis AJR 2012; 198:281-287: 64 lesions, upgrade 33% – 1= ADH; 1 LCIS and distant tiny ilc; 1 LCIS, DCIS (upgrade: 2%) (12 masses, 4 arch) (7 MR enhance: article shows spic mass); • 53 followed with no change (1-8 yrs) adjusted 23%, Bx: auto:n=4; dir/vac n=6 • (not broken down by grade of LCIS) – Niell (MGH); AJR 2012 199:929-35) 9% upgrade • Large detailed series: cases over 10 years – Stereo: large needle, 4 or more samples; US: 14G: 5 or more – 41%: immed surgery: LCIS: 9/39 (23%): malig samples; MR: ????number of samples • 3 cases pleomorphic, 6 cases discordant rad-path Rosenfeld (AJS: 2001: 182:1-5): When preop localization for “benign calc”---13% “incidental • Without these, only 2 ALH showed malig (1% upgrade) malignancy found at adjacent site
R. James Brenner, MD
214 LN not marking site of cancer Lobular neoplasia: When to excise (Rad 2012; 263:43-52, Quebec; Mod Path 2013; 26:762-771; Rad 2013; 269:340)
• Calc: 215 (78%), mass (12%) • Platform 1: always—”what me worry?” • 276 LN without surg: F/U 5 years (+/- 2.4) • Platform 2: never---risk factor, not local problem – Exclude rad path discord, palp, pleomorph (pure LN) • Cancer in 27 (9.8%) at mean of 3.9yr(+/-2.6) • Platform 3: Selective analysis 3 CANCERS (1.1% IN SAME quad) – Florid forms—increased incidence (40-60%) 87 cases: if no other high risk or known CA: follow • (4/10 (Sapino); 13/21 (Shin & Rosen)—higher ILC rate (3.7% upgrade if assoc high risk or concur Ca) • Often not reported, distinguish from “focal ALH” 43 benign concordant (surg 38, 2+yr f/u5): no upgrades – Pleomorphic form, esp with necrosis 7 discordant (mass, calc): two upgrade to DCIS – Insufficient sampling of lesion
R. James Brenner, MD R. James Brenner, MD
cc mlo CC Mag ML MLO cc mlo History of ALH, LCIS—5 years ago New Ca Prior scar New Ca Prior scar R. James Brenner, MD R. James Brenner, MD
Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat epithelial atypia ______Sclerosing Adenosis, Focal Fibrosis, phyllodes, columnar cell alteration (mucocele)
R. James Brenner, MD R. James Brenner, MD
215 R. James Brenner, MD R. James Brenner, MD
trans
long
Issue: Part of lesion may be benign, other part of lesion may not be
PAPPILARY LESIONS: WHOLE LESION MUST BE REMOVED
R. James Brenner, MD R. James Brenner, MD
Papilloma Papillary Ca—no actin
Excisional Biopsy
Core Biopsy Ann Surg Oncol 2009, July 20:
9% conversion to malig error: 15% borderline: 48% sampling issues: 37% Risk associated with atypia and >45 years old Fibrous rim around papillary
R. James Brenner, MD lesion R. James Brenner, MD
216 Papillary lesion CNB Papillary Lesions (Rosen,AJR 2002; 179:1185)/Mercado, Rad 2006; 238:3, Liberman AJR 2006; 186:1328) (Rad 2007; 2007; 242:58-62) • Rosen:46 lesions • Retrospective: 63 lesions (mass 41%, calc 43%, mass + • Surgery on 17 (37%) and f/u others mean 45 mos calc 16% • NPV 93%:Conclusion: okay to follow if no atypia – Surg: 38; f/u >24 mos: 25 • Mercado: 43 lesions; f/u 37 mos • 15: 14G; 38 vacuum assist(?G): mean: 8.7 cores • Surgery on 36 (84%) – Independent of needle size, # cores, location • 10 lesions (21%) upgraded to ADH(8), DCIS(2) • RESULTS: atypical papilloma: 67% malig • Liberman: 50 lesions, surg 25, 25 f/u median 22 mos • Otherwise: 3%: “okay to follow” (p sig) • 4 DCIS, 1 CA (node -),[malig 14%] 3 adh, 2 radial scar, 1 lcis • (sclerotic, micropapilloma) • (higher likelihood with mult; mammo removal not definitive) • Malig: DCIS (7), IDC (3), pap Ca (2); LCIS (2)
R. James Brenner, MD R. James Brenner, MD
Predictors of upgrade Potential Tissue Sampling Errors
• Rad 2011; 258:81-8 (Korea) 14 G only • Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH – 8/150 lesions (5%) upgrades from papilloma • Lobular Carcinoma In Situ • AGE :> 50; size >1 cm, location >3 cm from nipple(doubt) • Discreet Papillary lesions (r/o papillomatosis) • Rad 2012; 265:379-384 (St Louis): • Radial Scar – 14/128 (11%)lesions upgraded • Flat epithelial atypia – Factors: confidence of pathologist and number samples (p<.01); trend: mass ______vs calcifications, # bx Sclerosing Adenosis, Focal Fibrosis, phyllodes, Columnar • Br J 2013; 19:611 (Cleveland Cl, OH) cell alteration (mucocele) – 11G or G: no false neg 1.5 cm or less (2 yr f/u)
R. James Brenner, MD R. James Brenner, MD
Complex Sclerosing Lesion: Radial Scar
R. James Brenner, MD R. James Brenner, MD
217 STEREOTACTIC CNB: MULTI-SITE (Brenner, et al AJR2002; 179:1179) Radial Scar STUDY(BRENNER ET AL) • 157 lesions • DEFINITIONS: – Surg (n=102); f/u (median 38Mos) (n=55) • With atypia: 28% (8/29) malignant • STRICT: CNB-Histopathology correlation • Without atypia: 4% (5/128) malignant • WORKING: Consider ADH, LCIS true pos • All with fewer than 12 samples (# =5,5,5,6,11), spring load • APPLIED: Consider nonconcordant positive • One by US, 4 by stereo; all 14G mammo true pos • Two arch dist, 3 masses • NPV=95% w/o atypia; 100% if 12/more cores
R. James Brenner, MD R. James Brenner, MD
MULTI-INSTITUTION STEREOTACTIC CNB Follow up post benign Core bx (BRENNER, ET AL) • SENSITIVITY: • NO Yield at 6 month unless you think you • STRICT: 91% STRICT: PPV/NPV= 100/97 MISSED lesion • WORKING: 92% – No specimen confirmation for MR • APPLIED: 98% WORKING: PPV/NPV=93/97 – US: real time observation • SPECIFICITY: – Stereo: specimen radiograph • STRICT: 100% APPLIED: PPV/NPV=56/99 • Follow up one year sufficient: Dx • WORKING: 98% – If seen by US only, only need US follow up (exclude • APPLIED: 73% phyllodes)
R. James Brenner, MD R. James Brenner, MD
Clip and mass Cancer clip
clip
needle
mass Bx: FCD discordant
Wire Localization Anatomy of missed DX: IDC MRI BX Anatomy of a Missed Biopsy
R. James Brenner, MD R. James Brenner, MD
218 Underestimation of Disease-does it matter? • Myth: clustered microcalcifications are usually DCIS (10-60% invasive: Rad 1992:184:623-7) • Myth: calcs with density represent invasive Ca • (Rad 1994; 192:443-446) • GOAL: DEFINITIVE DX MAY AVOID SENTINEL NODE BX • BUT LARGE AREAS OF CALCS (e.g.—DCIS more than 4 cm) OFTEN PROMPT NODE SAMPLING
R. James Brenner, MD R. James Brenner, MD
Misplacement/migration of clips (Rosen, et al, Rad 2001; 218:510-6; AJR 2003; 181:1295-99)
• 111 pts • 28 % more than 1 cm away on at least 1 view
• 39% had bx=atypia or malignant=excision – 46% of these had clips > 1 cm away
– COMPARE COLLAGEN MARKER TO 1ST CLIP 5/31(16%) VERSUS 19/43 (44%) DISPLACED > 1 Different clips to mark different adjacent lesions CM R. James Brenner, MD R. James Brenner, MD
Epithelial Displacement ???Seeding
Seeding Brenner RJ, Gordon LA, Breast Journal
Carter et al (Am J Clin Pathol 2000; 113:259-265) R. James Brenner, MD
219 CC
R. James Brenner, MD R. James Brenner, MD
CC CC MLO mlo cc post lumpectomy-1 yr post bx
R. James Brenner, MD R. James Brenner, MD
SAG AX
R. James Brenner, MD R. James Brenner, MD
220 Potential Tissue Sampling Errors
• Atypical Ductal Hyperplasia (ADH) • Atypical Lobular Hyperplasia/ALH • Lobular Carcinoma In Situ • Discreet Papillary lesions (r/o papillomatosis) • Radial Scar • Flat Epithelial Atypia Phyllodes, Focal Fibrosis, PASH, Sclerosing Adenosis, Columnar alteration ( Mucocele) Ax
R. James Brenner, MD R. James Brenner, MD
221 222 223 224 NEGLIGENCE
DUTY o Production of satisfactory images ISSUES IN DETECTION BREACH o Reasonable Image Quality Interpretation CAUSATION Reasonableness of non recall Non-specific/subthreshold findings DAMAGES o Effective Communication R. James Brenner R. James Brenner, MD
Academic Radiology Slight difference In positioning
CC
R. James Brenner, MD R. James Brenner, MD
CC MLO CC MLO
R. James Brenner, MD R. James Brenner, MD
225 R MLO L R CC L
YR 1
2
3
YR X MLO YR Y R. James Brenner, MD R. James Brenner MD
R MLO L R CC L Year 1
YR 1
2
3
R. James Brenner MD MD R. James Brenner, Year 2
R. James Brenner, MD R. James Brenner, MD
226
L CC Year 2 L MLO Spot compression 1.5x Magnification, ML R. James Brenner, MD MD R. James Brenner,
February 2011 R. James Brenner, MD Courtesy: Hologic, Inc. R. James Brenner, MD
CC MLO
R. James Brenner, MD R. James Brenner, MD
227 Other Key History Reconciliations
• Prior US---check current problem list to see if lump
• Arch distortion—was R CC L R MLO L same as site of bx
R. James Brenner, MD
False Negative Mammograms: Errors in Diagnostic Radiology Medical Legal Considerations (AJR 2014; 202:465-470) • Complacency: finding assigned to wrong cause • Faulty reasoning: too limited ddx • Lack of knowledge: does not recognize issue R. James Brenner, M.D., J.D., FACR, FCLM • Underreading: missed Bay Imaging Consultants: Director, Breast Imaging • Poor communication: result does not reach MD Carol Ann Read Breast Health Center • Technique • Prior study: not compared Professor of Radiology • History: not received or incorrect University of California, San Diego • Location: corner call • Satisfaction of Search • Satisfaction of report: overrely on prior interpretation
R. James Brenner, MD
Missed Ca: screen/ interval: ffdm/film (Rad 2012 264:378-86: Norway)
FFDM Screen/film
Overall: 20%/33% 21%/30%
Prior findings for interval
Asymm 27% 10% Calc 18% 34% Mass size 10.4mm 13.6mm
R. James Brenner, MD
R. James Brenner, MD R. James Brenner,
228 Subthreshold Ca-Expert Review (Ikeda, et al, Rad 2003; 226:494-503 • Deliberate selection of 286 cases with subsequent CA (mean 14 mos) at sites of subtle abnormalities • Five blinded rads: 172 of these cancers were ID’s for recall by none, only 1, or only 2 rads
• 172 CA (75% invasive; median 10 mm diameter) • 137/172 (80%) had subtle findings on prior year mammogram
R. James Brenner R. James Brenner, MD
R. James Brenner RECALL RATES Correctable Causes of Missed Cancer (Yankaskas, AJR 2001; 177:543-549) 215,665 Screening mammograms • Old films: new densities • Misapplied work-up Low High • Attention to technical • Subthreshold findings
detail (especially with clinical Recall rates 1.9% 13.4% Sensitivity 65% 80.2% • Distraction: Satisfaction Sxs) PPV 7.2% 3.3% of search • Wrong assumptions • Difficult anatomic • Surgical mishaps CUT OFF POINT: RECALL RATE OF 4.8% position • DEFENSIBLE MISSES ---no sig higher sensitivity beyond this • Developing densities : RECALL RATE OF 5.6% ---sharp drop-off in PPV R. James Brenner R. James Brenner, MD
YR 1
R CC L R MLO L R CC L R MLO L
YR 2
R. James Brenner, MD R. James Brenner, MD
229 YR YR 1 1
R CC L R MLO L R CC L R MLO L
YR YR 2 2
YR YR 3 3
R. James Brenner, MD R. James Brenner, MD
Infiltrating Lobular carcinoma
YR 1
R CC L R MLO L Yr R MLO L 2 R CC L
TRAUMA
R. James Brenner, MD R. James Brenner, MD
MLO Yr 2 CC MLO Yr 3 CC ?Interval for comparison?
R. James Brenner, MD R. James Brenner, R. James Brenner, MD R. James Brenner,
230 MLO Yr 1 CC yr 1 yr 2 yr 3 R. James Brenner, MD MLO R. James Brenner, MD
R CC L R MLO L close up L MLO
yr 1 yr 2 yr 3
CC Comparison: “allowing for differences in ……….” R. James Brenner, MD R. James Brenner, MD
YR YR 1 1 R CC L R MLO L R CC L R MLO L
YR YR 3 3
R. James Brenner, MD R. James Brenner, MD
231 Comparing to show no change
• If looking at prior studies to show no change in YR one view asymmetry, better to go to earlier than 1 subsequent studies to avoid possibility that lesion MLO CC is slowly growing
Yr 6
R. James Brenner, MD R. James Brenner, MD
Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up YR 1 • Attention to technical • Subthreshold findings detail (especially with clinical MLO CC • Distraction: Satisfaction Sxs) of search • Wrong assumptions
IDC • Difficult anatomic • Surgical mishaps Yr position • DEFENSIBLE MISSES 6 • Developing densities
R. James Brenner, MD R. James Brenner, MD
Which one is Infiltrating ductal carcinoma?
R. James Brenner, MD R. James Brenner, MD
232 Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical • Distraction: Satisfaction Sxs) of search • Wrong assumptions Fibroadenoma IDC • Difficult anatomic • Surgical mishaps position • DEFENSIBLE MISSES • Developing densities Which one is Infiltrating ductal carcinoma?
R. James Brenner, MD R. James Brenner, MD
Rule of Multiplicity
MLO CC R. James Brenner, MD MLO CC R. James Brenner, MD
MLO CC MLO-close up
R. James Brenner, MD R. James Brenner, MD
233 1 1 CC CC MLO Yr CC Yr MLO MLO 2 2
YR 1 YR 2 R. James Brenner, MD R. James Brenner, MD
CC CC CC MLO MLO MLO R CC L R MLO L
US US
YR 1 YR 2 YR 3 R. James Brenner, MD
R CC L R MLO L R CC L R MLO L
ML CC
234 R CC L R MLO L R CC L R MLO L
Mo1 cc Mo 8 Mo 1 mlo Mo 8 Mo1 cc Mo 8 Mo 1 mlo Mo 8
Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up
• Attention to technical • Subthreshold findings
detail (especially with clinical
Sxs) • Distraction: Satisfaction
of search • Wrong assumptions
• Difficult anatomic • Surgical mishaps
position • DEFENSIBLE MISSES CC Yr 1 MLO CC Yr 2 MLO • Developing densities
R. James Brenner, MD R. James Brenner, MD
CC
YR 1
MLO CC Status post mastectomy 7 years ago
CC Yr 2 MLO Now palpable
Yr 3 MLO YR 2
Ex CC Yr 3 MLO
R. James Brenner, MD R. James Brenner, MD
235 R CC L R MLO L
YR YR 1
1
CC MLO
CC MAG ML 2 Yr 3
R. James Brenner, MD R. James Brenner, MD
CC ExCC Yr 2 MLO CC MLO Yr1 MLO Yr 1
R. James Brenner, MD R. James Brenner, MD
YR 2
R MLO L R CC L Very Superficial lesion
Yr 1
MD Brenner, James R. Right MLO Left R. James Brenner, MD
236 Correctable Causes of Missed Cancer From SF Chronicle 8-22-10
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical People Magazine 12-30-13 • Distraction: Satisfaction Sxs) of search • Wrong assumptions • Difficult anatomic • Surgical mishaps position • DEFENSIBLE MISSES • Developing densities
R. James Brenner, MD R. James Brenner, MD
Initial
Patient started Birth control Pills 3 years ago
Adeno CA developing against chronic interstitial pneumonia (Yoshida, et al, AJR 2012; 199:85-90) Next Mammo “recapitulates 4 yrs later breast tissue pattern”
R. James Brenner, MD R. James Brenner, MD
CC MLO
YR YR 1 1
R CC L R MLO L YR 2
Not seen at US= YR Rec f/u 6 mos 2 And
YR YR 3 2.5 Seen US 6 months later” when Associated with soft tissue, not fat R. James Brenner, MD R. James Brenner, MD
237 R CC L R CC L
YR 1 R CC L R MLO L
YR 2
YR 1 YR 2 ML Difficult to see change on MLO R. James Brenner, MD R. James Brenner, MD
Yr 1 MLO Yr 2
R. James Brenner, MD R. James Brenner, MD
R. James Brenner, MD R. James Brenner, MD R. James Brenner, MD R. James Brenner, MD
238 R MLO L R CC L R CC L R MLO L
Yr 2: 1.0 cm
Yr 3: 1.7 cm
R. James Brenner, MD R. James Brenner, MD Yr 4: cluster PLUS new mass
YR 1 YR 1
YR 2
Yr 2
Yr 3
R. James Brenner, MD R. James Brenner, MD
YR 1 R CC L R MLO L
YR 2
Large cell B lymphoma
R. James Brenner, MD R. James Brenner, MD
239 YR YR 1 1 R CC L R MLO L R CC L R MLO L
YR YR 2 2
R. James Brenner, MD R. James Brenner, MD
R MLO L R CC L
YR R CC L 1 R MLO L
YR 2
R. James Brenner, MD R. James Brenner, MD
R MLO L R CC L R MLO L R CC L
YR YR 1 1
Yr Yr 2 2
Yr 3 lump ultrasound
R. James Brenner, MD R. James Brenner, MD
240 Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical • Distraction: Satisfaction Sxs) of search • Wrong assumptions • Difficult anatomic • Surgical mishaps position • DEFENSIBLE MISSES • Developing densities R CC L R MLO L
R. James Brenner, MD R. James Brenner, MD
YR YR 1 1
R CC L MLO L R CC L MLO L
YR YR 2 2
R. James Brenner, MD R. James Brenner, MD
R/L YR CC 1
Yr 1 Yr 2 Yr 3 R CC L MLO L
R/L YR MLO 2
R. James Brenner, MD R. James Brenner, MD
241 R/L CC
R. James Brenner, MD R. James Brenner, MD
R CC L R MLO L R CC L R MLO L
Right Incorrect Left (supf) Correct Left=deep R. James Brenner, MD R. James Brenner, MD
CC ML MAG CC MAG MLO
First US (too superficial) Second US--CA
R. James Brenner, MD R. James Brenner, MD
242 MAG CC MAG MLO
Probable CYST Definite
R. James Brenner, MD R. James Brenner, MD
Rad-Tech Discrepencies: screen US (Exhibit: ARRS 2014; Br Cancer 2012; 19:138-46)
• Yale: – 81% of consecutive 336 pts scanned by tech: neg/B9 – 76 patients scanned by MD: 6.5% disagree • Japan: 442 MD & 415 Tech(special training) • Sens and specificity on video, and still images are comparable (within 1%) • Those with less experience of < 100 cases showed worse performance
R. James Brenner, MD R. James Brenner, MD
R. James Brenner, MD R. James Brenner, MD
243 New smooth mass With central macrocalcification YR 1
CC MLO
CC MLO close up-mlo
YR 2
“Dirty cyst=complicated cyst
Infiltrating ductal ca
R. James Brenner, MD R. James Brenner, R. James Brenner, MD
Yr 3 MLO Yr 1 CC Yr 3 MLO
YR 3 MLO YR 1 R. James Brenner, MD R. James Brenner, MD
YR 1 YR 3
Yr 3 MLO Yr 1 CC Yr 3 MLO
Yr 4 R CC L R CC L NEW architectural distortion
R. James Brenner, MD R James Brenner MD
244 Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical • Distraction: Satisfaction Sxs) R CC L R MLO L of search • Wrong assumptions ISSUE: recurrence • Difficult anatomic • Surgical mishaps vs position • DEFENSIBLE MISSES scar • Developing densities
Especially for screening US R. James Brenner, MD R. James Brenner, MD
R L R L
CC CC
R L R L
MLO MLO
R. James Brenner, MD R. James Brenner, MD
R L Correctable Causes of Missed Cancer CC
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical • Distraction: Satisfaction Sxs) R L of search • Wrong assumptions MLO • Difficult anatomic • Surgical mishaps
position • DEFENSIBLE MISSES
• Developing densities
R. James Brenner, MD R. James Brenner, MD
245 Doppler flow in solid portion
HX: 1 year ago, similar mass Core Bx shows blood and R CC L R MLO L Blood clot, concordant benign As mass decreased in size Hx: 54 y.o.: “I’ve had a right breast lump for 5 yrs, my doctor knows all about it, it’s fine He only ordered and I want a screening mammo” R. James Brenner, MD MD R. James Brenner,
CC
MLO
Yr 1 2 3 4 5
MLO CC CC MLO
R. James Brenner, MD R. James Brenner, MD Brenner, James R.
CLARIFY: “nodularity, enlargement” Thickening, mark/no description
“Lump until proven otherwise” ML
R. James Brenner, MD
246 MLO
YR 1 YR 2 Yr 3 Yr 4 Yr 5
CC
ML CC
R. James Brenner, MD MLO CC Yr 6
Year 1 Year 3
MLO CC MLO CC
Year 1 Year 4
MLO CC MLO CC R. James Brenner, MD R. James Brenner, MD
Year 4
MLO CC Year 1
MLO CC
Year 6
Year 4
MLO CC
MLO CC
R. James Brenner, MD R. James Brenner, MD
247
CC MLO
Year 3
MLO CC Stable x 5 yrs
new Year 6
MLO CC
R. James Brenner, MD R. James Brenner, MD
Suspicious lesions that Do not change REMAIN suspicious e.g.—clustered calcs
CC Year 1 MLO R. James Brenner, MD R. James Brenner, MD
Yr 1 CC Yr 3 Tubular carcinoma---no change (mammo) 3 yrs R. James Brenner, MD R. James Brenner, MD
248 Y r R MLO L R CC 1 R MLO L year 1 R CC L L
Y r
R James Brenner MD 2 R. James Brenner, MD
Yr 2
Year 3
R. James Brenner, MD R James Brenner MD
No change mammo pattern x 3 yrs Prior contralateral Mastectomy: dimpling X 2 months, no lump Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical CC ML • Distraction: Satisfaction Sxs) spot mag of search • Wrong assumptions • Difficult anatomic • Surgical mishaps position • DEFENSIBLE MISSES • Developing densities
No architectural distortion R. James Brenner, MD R. James Brenner, MD
249
Specimen xray
Not the same calcifications R. James Brenner, MD R. James Brenner, MD
R. James Brenner, MD R. James Brenner, MD
Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical Sxs) • Distraction: Satisfaction R CC L R MLO L of search • Wrong assumptions • Difficult anatomic • Surgical mishaps position • DEFENSIBLE MISSES • Developing densities
R. James Brenner, MD R. James Brenner, MD
250 Arrow shows lump for us
YR 1
R CC L R MLO L R MLO L R CC L
YR 2
R. James Brenner, MD R. James Brenner, MD
CC Yr 1 MLO R. James Brenner, MD CC Yr 2 MLO R. James Brenner, MD
Non specific R MLO YR 1 L YR 1 Yr 2
Subthreshold finding now threshold due to 1. Palp 2. skin thickening R MLO L Cc R MLO R. James Brenner, MD R. James Brenner, MD
251 YR 1
R CC L R MLO L R CC L R MLO L
YR Which density is the culprit? 3
R. James Brenner, MD R. James Brenner, MD
YR 1
YR R CC L R MLO L 1
CC MLO
YR 3
Yr 3
R. James Brenner, MD R. James Brenner, MD
Correctable Causes of Missed Cancer
• Old films: new densities • Misapplied work-up • Attention to technical • Subthreshold findings detail (especially with clinical • Distraction: Satisfaction Sxs) of search • Wrong assumptions • Difficult anatomic • Surgical mishaps position • DEFENSIBLE MISSES • Developing densities
R. James Brenner, MD
252 253 254 255 256 Controversies in Use of MRI for Breast MRI for extent of disease and staging and extent of disease staging
R. James Brenner, M.D., FACR Director, Breast Imaging, Bay Imaging Consultants Re-excision rates for CA: 4-43% Professor of Radiology University of California, San Diego (does not predict recurrance rate!)
1. Cellini C, et al. Am J Surg 189; 662-6; 2. Chagpar AB, et al. Am J Surg 2004; 188:399-402 R. James Brenner, MD
Issues in MRI staging of breast cancer MRI and Re-excision: 2 RCT
• COMICE (Comparative effectiveness of MRI in • MONET (Mammography of nonpalpable breast • Current adjuvant techniques; may not matter: inert breast cancer) tumors) disease • 1625 women candidates for BCT • Dutch trial—other Dutch trial • Milan and NSABP 20 yr f/u of conservation therapy vs by mg/us/clinical (MRISC) showed MRI found twice – 70% of total candidates excluded as many CA as Mg (Mg sens:33%) mastectomy: no change in outcome or refused to participate (but • Issues: Re-excision prospective and randomized • Increased re-excision with MRI • Recurrence • No difference Re-excision (34% vs 12%) • Expense • Candidates for • Issues: • Issues: – MRI quality (8% inad) – Breast Conservation Therapy: conversion to MastX (FP and FP) – MR excision smaller based on MR • 1.6% contralateral – Bias to calc only malignancies – APPI: Accelerated Partial Breast Irradiation: U. Chicago 8-11% – Few MR Bx would not be eligible by RTOG std. (suitable: post menopausal, < (50%) as MR done on screen 2cm) VS RTOG 9517: % recurrence median f/u 12 yrs – 70% post meno (fatty) detected Ca – SAME 11% :Meta analysis Rad 2015; 277:716-726
R. James Brenner, MD R. James Brenner, MD
Preop MRI of Breast: Prospective randomized Local Recurrence multicenter study in Sweden (World J Surg 2014; 38; 1685-93) Main issue: too little follow up time • 440 patients <56 y o (surrogate for dense breast) • Fisher: (Euro Rad 2004) • Solin: JCO 2008 • 20 mo f/u: p < .001) • Lower reoperation rate: 5% vs 15% (p<.001) • Med 4.6 yr f/u: early stage • 1.6% with MRI Ca • Altered treatment plan 18% (eg-considered for • 6.8% without MRI • (not powered for p value) conservation converted to mastX=15%) • RAD 2015: (Korea) • 3% w MRI • Total number MastX same • F/ u 6.1 yrs median • Tripple neg tumors • 4% without MRI • Issues in study: MRI not optimal (late “high res study,” • 50% MR only after postive few MR bx available, some not randomized until after • 2.6 x more recurrence margins—more likely preRx (16%) without MRI recurrence • R. James Brenner, MD R. James Brenner, MD
257 Recurrence with/without MRI Pre-op planning and recurrance (Korea: RAD 2015; 276:695-705) (AJR 2014; 202:1376-1382): 8 year follow up
• 468 patients: • Retrospective stage 0-2; 2000-2004: 174 women – 371: Unilateral MRI vs no MRI with MRI vs 174 without; matched to surgeon – 97: Bilateral MRI vs no MRI • Similar negative margins, LN status, EIC, Rx, • Uni: better localregional recurrence (p.44) but no hormone status; MRI biased for dense breasts difference in contralateral or distance recur (p.5) • Weak p values • Bilat: better contralateral recurrence (p.001) but – MRI needed fewer re-excisions p=0.02 no difference in localregional or distant recur (p. – No dif locoregional recurrance p=0.33 18) – No dif disease free survival p=0.73 R. James Brenner, MD R. James Brenner, MD
Impact on Treatment with MRl: change of stage, MRI accuracy, impact on Rx RX (Houssami, JCO 2008; Ann Surg 2013 (with Morrow) (Rad 2016; 279:378) • Meta analysis 19 studies • 17/73 patients (23%): MR detected multicentric Additional disease (16%) (n=2610); ppv=66%* lesions larger than index cancer PET/CT if neg for lesions > 1cm, “might avoid bx” --few lesions studies (AJR 2016; 206; 891) – 16%: added cancer 1.4-2 cm Conversion to mastectomy 8.1%; Wider excision: 11.3% – 8%: added invasive cancer > 2 cm New Metaanalysis: 2 radomized, 7 comparative cohorts Conversion to Mastectomy 18% to 25%; for ILC 25% to 31%; sigp DO not recommend MRI—Issues with conclusions: ignores 4% • 27/73 (37%) differed from index cancer with contralateral incidence; pt pref, issue of better selection of APBI respect to invasion, grade, and/or receptor status
R. James Brenner, MD R. James Brenner, MD
Specific Indications for MRI?
• Molecular Subtype • MultiCentric lesions • (Radiology 2014: Duke) • (Rad 2016, Italy and Korea) • Luminal B and Her 2 +: more often multi focal/ • Multicentric lesions less centric and LN + aggressive • 10% 441 Ca:Lum B • Tripple neg: more • 5% 441 Ca Her2 + recurrence without MRI • No outcome data • (influence: LVI, dense, f/h) AX SAG
2nd primary not close to first R. James Brenner, MD R. James Brenner, MD
258 Impact of MRI on BIRADS 4 lesions MRI and Mastectomy: Mayo Clinic (Radiology 2014, Germany) (JCO 2009; 27: 4982-4088) • Increased PPV from 18.7% (66/353) to 73% • 5405 pts (5583 Ca) Stage 0-2, all histologies (66/86) – Initial decline in mastectomy 43% (1997) to 31% (2003), and then increase to 43% (2006)(SEER :40 to 37%) • Helped detect benign correlate for as many as • MRI: patients more likely to undergo mastectomy 264 of 287 lesions – 36% (1997) vs 54% (2006) • 135/353 cases (38%) underwent bx • NO MRI: patient more likely to undergo mastectomy – Follow up > 24 months 20 pts (26%) – 29% (2003) to 41% (2006) – non malig MRI findings: 33 (42%) – NPV 100% excluding calcifications R. James Brenner, MD R. James Brenner MD
ACRIN 6667 Issues: staging and extent of disease (Rad 2014; 273:53-60) • Patient driven factors, not MR recommendations • Chest Wall invasion account for increased prophylactic mastectomy • Extent of index malignancy – Family history • Multifocality and Multicentricity – Increased breast density • Axillary (and regional) node involvement – DCIS as index malignancy in ipsilateral breast • Contralateral lesions--synchronous
R. James Brenner, MD R. James Brenner, MD
?Pectoral Muscle (chest wall) Invasion [NCNN: chest wall Not equiv to pect muscle]
Axial SAG
Pectoral muscle enhance: surgery: Pect invasion R. James Brenner, MD
259 Axial SAG
Recurrent ILC: path rib fx
R. James Brenner, MD Courtesy: Linda M. Gordon, MD R. James Brenner, MD
Predicting Residual Disease (Am J Surg 2009; 198:547-52)
43 women post surg 20 (69%) had residual dz 9 false positives less sensitive to dz after 28 days
Chest Wall Invasion
R. James Brenner, MD R. James Brenner, MD
Axial Sagittal MIP Invasive Lobular Carcinoma
Axillary tail
R. James Brenner, MD R. James Brenner, MD
260 R CC L R MLO L R CC L R MLO L
R. James Brenner, MD R. James Brenner, MD
R. James Brenner, MD
R CC L R MLO R CC L R MLO L L Calcification = FCD
R James Brenner MD
R CC L R MLO L US
Calcifications = DCIS
AX MRI SAG R. James Brenner, MD R. James Brenner, MD
261 AX AX SAG
R CC L R MLO L
ILC and LCIS VS IDC + Intrammammary LN Measure 3.2 cm IDC: 6.1 cm
R. James Brenner, MD R James Brenner, MD
Male
R CC L R MLO L US
nd SAG MRI 2 lesion infr-medial=LN CC MLO
2nd mammographic lesion better Seen as suspicious AFTER MRI
R. James Brenner, MD R. James Brenner, MD
Contralateral disease: 4% over next 10 years: 5-10% Lesion 2 If BRCA: 30% If young with F/H: 15%
Lesion 1
Contralateral non specific: idc, 5 mm
Lesion 3 PEM (73%) not as good as MRI (93%) AJR 2012; 198:219 (anything that lights up Should be suspicious) R. James Brenner, MD
262 L.N.
Close up: MRI Lymph node with metastasis R. James Brenner, MD
Axial
Sag Ax Sag
When to worry about Intramammary LN? N1 disease: NO DATA R. James Brenner, MD R. James Brenner, MD
HX: status post Right MastX 20 Years ago; current Endometrial CA met w/u PET-FDG SUV 4.2
Inflammatory Breast Cancer: skin involvement
R.James Brenner, MD MLO CC R. James Brenner, MD
263 Vessel taking May have Off –not LN Duplicated Intr mam artery
History of Ovarian CT Internal Mammary Node MR cancer
R. James Brenner, MD R. James Brenner, MD
Internal Mammary(Thoracic) Lymph Node (AJR 2015; 205:899-904; 2015; 205:209-214)
• 90 pts with IIA-IIIA disease • MRI Detection: 16% (14/90) T-1 with contrast/vibrant T2 FSE • PET/CT 14% (13/90) (p=.317)
• 4.5 mm: 50% of asymptomatic high risk women
R. James Brenner, MD R. James Brenner, MD
Sternal Suture metalic artifact May obscure Internal Mammary Nodes
Retained Wire Fragment R. James Brenner, MD R. James Brenner, MD
264 R. James Brenner, MD Use of MRI for Neoadjuvant: comparison AJR 2005; 184:868-877; RAD 2011; 261:735-743
• pCR: sensitivity: 80%, specificity: 89% • (Bhattacharynya M, Br J Cancer 2008; 98:289-93) • Other earlier predictors: – DIFFUSION WEIGHTING MAY PREDICT RESPONDERS (Rad 2010; 257:56-63) – RAD 2012;263:53: 2 cycle specificity: %SUVmax 96%;MR kinetic transport models 92% – US-near infrared Hb (Rad 2013; 266:433) Biomarker • ISSUE OF TAXANES (Rad 2015; 277: 687-695) • Taxanes appear to reduce ENHANCEMENT unrelated to oncologic response (also background, B9 mass)
R. James Brenner, MD
Prognostic features (Rad 2016; 279; 44 ACRIN 6657/CALGB
Volumetric response at After 1st cycle has high RFS Px (esp with oncotype) Pre-NeoRx Post-NeoRx Pre CC Post Pre MLO Post More for EP+/her (-) and Her (+) than tripple neg
Axial AJR 2016; 206:846
PET/CT for recurrent Ca: Volumetric TLG (total lesion
Glycolosis + SUVmax and SUVpeak Sag May predict OS R. James Brenner, MD R. James Brenner, Issue: size, kinetics, CR w herceptin MD R. James Brenner,
NPV for suspect lesions: use of MRI
• Rad 2015; 274:343-51 (Germany) – NPV 100% for lesions by mg or US that were NOT PRE Neoadjuvant RX POST pure clustered Calc (false neg 12% for cluster Calc)
– (Birads 4 on 340 patients by screening mg or US; – No bx: F/u >18 months for lesions; >24 mos for calc – Incidental MR true Pos findings in 5/340=1.5%
NO Residual Malignancy: better Predictive value ? using Volume Based Imaging response Rad 2016 ACRIN R. James Brenner, MD R James Brenner MDP
265 NPV for suspect US lesions FALSE NEGATIVES (Br J Radiolo 2014; 87 (from Turkey) • 227 lesions, all US bx, BIRADS 4,5: retrospective clip • NPV: 91% (sens 94%, Spc 56%, PPV 68%) • For B4 only: NPV 94% • 42% of B9 biopsy could have been avoided with false neg rate of 2.6% • ISSUE: ACRIN 6666: no lesions seen by US not MLO CC seen by MR and many MR cancer not seen US Low grade DCIS: no enhancement
R. James Brenner, MD R. James Brenner, MD
Overlapping and genu points of Vessels and slight motion: most common false positive finding (RJB) (ignore single pixels of red)
AXIAL
YR 1 mass: 7 mm Y2 2 mass: 11 mm SAG SAG
MRI guided 9 gauge bx: ALH SAG
Surgery: 6 mm IDC BENIGN MR BX-no specimen—REC repeat one year R. James Brenner, MD R. James Brenner, MD
R. James Brenner, MD R. James Brenner, MD
266 Extramammary findings: Breast MRI
(Rad 2015; 276:56-64)) • 2324 pts: 17% with findings – 4.5% with E3 or E4 findings (from C-Rads) – 3.7% after checking that other finding already known Sag Axial • Clinical important findings: 0.4% (n=9) – Usually related to Liver prompting Abd MR Vessel • Compare with other extrastudy findings – CT colonogrpahy: 4-10% – Lumbar CT 4% – Body CT 3.4%
R. James Brenner, MD R. James Brenner, MD
R. James Brenner, MD
267 268 269 270 Case 1: 67 Y/O MALE WITH LEFT BREAST PALPABLE FINDING
Ultrasound case review
A) Benign, surgical consult Mohammad Eghtedari, M.D., Ph.D. without biopsy [email protected] B) Needs Biopsy
C) Biopsy then surgical consult Special thanks to Dr. Ojeda for sharing her cases with me
NCI
Designated Comprehensive Cancer Center
Case2: 83 y/o female with palpable left axillary mass Case 3
A) Benign, may offer You find a breast mass by US that was recently biopsied breast MRI B) Needs prior and was found to be metastatic melanoma. No other finding C) Biopsy is seen on your exam. What is the appropriate BI-RADS?
A) 1 B) 2 C) 6
Case 4: 43 y/o female with left breast palpable Case 5: 46 y/o female with right breast palpable finding, Which one is incorrect finding
A) Benign complex cystic and solid mass A) Most likely benign, 6 month follow up B) Biopsy and surgical consult B) Biopsy C) Complicated cyst, follow up exam in 6 months C) Surgical consult without biopsy
271 Case 6: 66 y/o female with change in mammograms Case 7
Which one of the following is NOT an acceptable term to describe the shape of a mass on ultrasound:
A) Microlobulated B) Oval
2008 2010 2012 C) Round D) Irregular A) Probably benign, 6 month follow up B) Biopsy C) Surgical excision without biopsy D) MRI
Case 8: 24 y/o female with palpable finding Case 9
A) Follow up in 6 months True or false: Architectural distortion is a valid term to (may consider biopsy) B) Biopsy and surgical describe an ultrasound finding. excision C) Benign, no follow up A) True B) False
Case 11: 39 y/o female with palpable right breast Case 10: 43 y/o female with palpable right breast mass
A) Fat necrosis A) Likely FA, 6 months B) Lipoma follow up C) Invasive lobular carcinoma B) Surgical consult, no D) Hamartoma biopsy needed C) MRI (if available) D) Biopsy
272 Case 12: 67 y/o with a right breast lump Case 13: 22 y/o female with palpable left breast
A) Follow up in 6 months B) Follow up in 2 months C) Biopsy
A) Benign, follow up in 6 months B) Biopsy C) Biopsy and surgical consult following biopsy regardless of biopsy results
Case 14 Case 15: 43 y/o with a palpable mass
Which one of the following is used to describe tissue A) Scar tissue follow up B) Extracapsular silicone composition on screening ultrasound: no follow up needed C) Extracapsular silicone MRI without contrast A. Heterogeneous fibroglandular tissue D) Biopsy B. Heterogeneous background echotexture C. Heterogeneous dense tissue
Case 16: 57 y/o female with left breast palpable Case 17: 62 y/o female with clear left nipple finding discharge
A) Benign intraductal papilloma follow up B) Biopsy (core or FNA) C) Ductogram to evaluate for additional masses D) Breast MRI
A) FA, probably benign follow up in 6 months B) Wide surgical excision, no biopsy C) Biopsy
273 Case 18: 54 y/o with new abnormal mammographic Case 19: 66 y/o with palpable left breast mass finding
A) Biopsy, could be invasive ductal carcinoma B) Biopsy, could be invasive lobular carcinoma C) Both A and B D) Follow up in 6 months
A) Biopsy B) Biopsy, will need surgical excision regardless of biopsy results C) Benign
Case 20: 61 y/o female with palpable in the right Case 21: 40 y/o female with right bloody nipple breast discharge
A) Biopsy B) Ductogram C) Surgical excision, no biopsy needed D) Breast MRI
A) Biopsy, could be benign B) Biopsy, surgical excision would be needed C) Follow up in 2 months, biopsy if change in size D) Breast MRI
Case 23: 67 y/o female with recently diagnosed right breast cancer based on outside biopsy
A) Size of tumor is T2 B) Size of tumor is T3 C) Needs transverse view to determine size D) Needs prior images to evaluate the size of malignancy!
274 275 276