Breast Imaging. Jamie L. Wagner, DO, FACOS. Digital vs Analog Mammography (2-D) Surgical Oncologist. Patient with Cancer. Radiology/ Interventional

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1 Breast Cancer Prevention, Treatment, and Survivorship Jamie L. Wagner, DO, FACOS Assistant Professor Chief, Division of Breast Surgery Department of Surgery Anesthesiology Surgical Oncologist Patient with Cancer Radiology/ Interventional Endoscopist Reconstructive Surgeon Breast Imaging Digital vs Analog Mammography (2-D)

2 Tomosynthesis (3-D) How does tomosynthesis work? 15 low dose projection images. Automated Breast Ultrasound (ABUS) 9 Negative 2D mammogram 1.4 cm cancer seen as mass with spiculation. Benefit of Digital Breast Tomosynthesis (DBT) and Automated Breast Ultrasound (ABUS) 2

3 Coronal Hand held 18 3

4 19 20 ABUS and DBT MRI 21 4

5 Known Malignancy Right breast US-guided core needle biopsy: IDC, grade 2, with DCIS 5

6 Left breast US-guided core needle biopsy: IDC, grade 2 Breast Cancer Treatment Breast Surgery Lumpectomy + Radiation = Mastectomy Breast Conservation Surgical Challenges Wire Localization Biopsy proven non-palpable malignant lesions Suspicious lesions on imaging unable to undergo percutaneous biopsy Location Patient technical limitations Excisional biopsy required due to discordance between pathology and imaging Response to neoadjuvant therapy Single localization Bracketing localization 6

7 Wire localization Limitations Surgical approach may be limited Wire migration Surgery and Radiology co-dependent Unable to be first case OR delays Patient discomfort Patient and physician inconvenience RSL Overview RSL - Radioactive Seed Localization Iodine-125 seeds implanted in breast Iodine-125 half-life of 60 days Seed activity of 0.1 mci Seed used for localization not therapy Presents a slight external hazard Sealed source does not present an internal hazard Advantages of RSL Seeds can be placed up to 5 days prior to surgery Allow uncoupling of the radiology and surgical schedule Easier on patient No evidence of migration I 125 and Tc 99m are of different Geiger counter peaks allowing lymphoscintigraphy to still be performed Performed with existing equipment in the OR Surgeon is unrestricted of incision location and approach Potential for smaller volume of breast specimen 7

8 US guided seed placement

9 Pathologic processing Specimen radiograph single seed Radiation exposure I-125 lower energy photon then Tc-99m Lower external hazard I-125 energy = 35keV Tc-99m energy = 140keV Low dose Tc-99m injected in the OR 4X activity of I-125 seed used for localization Seed in sealed container Safe to work around Breast Cancer Treatment Radical Mastectomy Total Mastectomy 9

10 Skin Sparing Mastectomy Nipple Sparing Mastectomy Recurrence Risk Nipple Sparing Mastectomy Recurrence Risk Nipple Sparing Mastectomy Recurrence Risk Nipple Sparing Mastectomy Recurrence Risk Nipple Sparing Mastectomy Complications % 10

11 Nipple Sparring Mastectomy NSM dissection of skin flaps NSM dissection of NAC base Before After Axillary Node Dissection Nodal Surgery Courtesy of Dr. Kelly Hunt, MDACC Axillary Lymph Node Dissection Goals accurate staging information regional control No benefit in removal of healthy lymph nodes Complications of ALND Lymphedema Shoulder dysfunction Paresthesias/Pain Persistent seroma 11

12 Nodal Surgery Sentinel Lymph Node Dissection Definition: A sentinel lymph node (SLN) is best defined as any node that receives direct lymphatic drainage from a primary tumor site Status of the SLN is predictive of the status of the nodal basin First reported in breast cancer by Krag et al in 1993 ALND SLNB Node that contained the first metastasis and the corresponding percentage of patients 1.16% Yi M et al. Cancer % 6th-9th:0.9% 5.2% Sentinel lymph node dissection Axillary lymph node evaluation Goals accurate staging 16.5% 74.5% Node that contained the first metastasis 1st 6th 2nd 7th 3nd 8th 4th 9th 5th Benefits SLN spares node negative patients ALND More than 99% of positive SLNs were identified in the first 5 nodes removed ACOSOG Z0011 Z0011: Local-Regional Recurrence Median follow-up = 6.3 years ALND N=420 SLND N=436 Local 15 (3.6%) 8 (1.8%) Primary Objective: To assess whether OS after SLND alone was not inferior to that for patients who underwent completion ALND for a positive SLN Regional 2 (0.5%) 4 (0.9%) Total 17 (4.1%) 12 (2.8%) Giuliano A, et al. Ann Surg,

13 Alive (%) Z0011: Overall Survival ALND No ALND P=0.25 Median follow-up: 6.3 yr Z0011: Conclusions The routine use of ALND is not justified and may be safely omitted in selected patients with clinically node-negative disease who are found to have a positive SLN Years Giuliano A, et al. JAMA, 2011 ACOSOG Z1071 Can we really save the nodes? 13

14 The next nodal generation How common is breast cancerrelated lymphedema? 87% 40%? 20% 39% 3% 10% Breast Cancer Related LE Studues Arm Circumference Measures Author, year No. LE classification LE Incidence patients cm % Langer, > Lucci, > 2 19 Armer, > 2 70 Temple, > 2 0 Haid, > 2 21 Herd-Smith, > 1 16 Petrek, > 1 49 Velanovich, > 1 8 Kiel, > 1 35 Keramopoulos, > 2 17 Gerber, > 2 56 Werner, > Total No. Patients 3,859 21% Breast Cancer Related LE Studies - SLNB No. Incidence Author, year Patients LE (%) Langer, Mansel, Francis, Wilke, Lucci, Purushotham, NR Leidenius, Annual 4 Cases of Breast Cancer = 184,000 Ronka, ~ 50% clinically node neg. = 92,000 Langer, Blanchard, ~ 70% 6 pathologic node neg. = 64,400 Haid, % 4Risk LE following SLNB = 3,864 Swenson, Schijven, Sener, Schrenk, Total No. Patients 4,241 6% Circumference Measures Most common method Measurements taken at various points Formulas available for estimating volume (cylinder or frustum) 14

15 21 st Century Lymphedema Measurement Tools Perometer Optoelectronic limb volumeter Infrared perometry Imaging device Measures limb volume, circumference, contour, cross-sectional area Perometer Convenient Quick Precise Easy to use Provides graphic record of limb volume No contraindications Perometer Problems with Perometry Limitations Immobile patients bariatric wheelchair bound unable to position limb Non limb edema truncal head/neck genital Bioimpedance Spectroscopy (BIS) L-Dex TM U400 Direct measure of tissue resistance to an electrical current to determine extracellular fluid volume Designed specifically to assist clinicians in assessment and monitoring of lymphedema Portable Easy to use Software for tracking patient results Approved for use of upper extremity measures by the U.S. Food and Drug Administration Bioelectrical Impedance Analysis Measures the body s opposition to flow of an applied electrical current Low current flows thru the path of least resistance which is the tissues with the highest water content in the ECF space Low frequency (<30kHz) = ECF 15

16 Results interpretation: Assessing lymphedema L-Dex Selfreport Volume Cornish et al. Lymphology Mar;34(1):2-11. Problems with Bioimpedance Expensive ($$) Not yet established in routine practice? Impedance Ratio? L DEX Ratio Limited use in bilateral swelling, truncal, head/neck Contraindicated in patients with pacemakers or defibrillators Factors That May Influence Bioimpedance Readings diuretics menstruation renal or heart failure artificial limbs / orthopedic hardware excessive exercise 2 hours before excessive alcohol consumed <12 hours Anything is better than nothing! Sequential Circumferential Measurement Perometry Bioelectrical Impedance Other Summary Thank you Many advances in breast cancer treatment have significantly improved survivors The best is yet to come St Agatha-the patron saint of breast cancer 16