Breast Imaging: From Predictive to Participatory

Transcription

1 Breast Imaging: From Predictive to Participatory T. Helbich Department of Radiology Division of Molecular and Gender Imaging Medical University of Vienna P4 Medicine in Breast Imaging: What can we offer already? Predictive Personalized Lessons learned! Preventive Participatory What to improve? P4 Medicine in Breast Imaging Predictive: Screening tools for early and accurate diagnosis: leads to early intervention & less chronic disease Mammography-screening! Test which searches for otherwise occult BCA Strong evidence that this test impacts BCAmortality (reduction up to 35%) Invasive ductal BCA 9 mm

2 Cumulative survival by tumor size Summary of MG- Screening trials mm mm mm mm mm > 50 mm YEARS L. Tabar, et al. Cancer 1999; 86: Perry N. Int J Fertil Mortality reduction by MG- Screening according to WHO MG-Screening: NO! 0,12% 0,10% 0,08% 0,06% NO Screening Screening Screening minor effect in mortality Mortality reduction mainly due to treatment Overdiagnosis! No justification for MG screening 0,04% 0,02% 0,00% AGE Jorgensen et al. Radiology 2011 MG-Screening and BCA mortality in Norway MG-Screening: YES! 2 study groups: 1,MG-screening 2,NO-screening ( ) 2 control groups: historical data ( ) mirroring the 2 study groups Screening: more lives saved than harm 2 to 2.5 lives saved for every overdiagnosed case Provide information about pros and cons for MG screening Women have to decide if they want to participate MG screening leads to mortality reduction Kopans et al. Radiology 2011 Duffy et al. J Med Screen 2011

3 Why do we miss breast cancer? 15-30% The principles of Tomosynthesis Contrast poor Superposition Malpractice/overlooked Improve Contrast: Digital MG Contrast Enhancement Tomosynthesis, US QM, Training MG vs. DBT MG vs. DBT Breast Tomosynthesis Breast Density & BCA-Risk Tomo higher sensitivity for BCA detection than digital mammography NEED for CAD Systems Boyd et al, NEJM 2007 Boyd et al, Cancer Epidemiol Biomarkers Prev 1998

4 Breast Ultrasound US - Elastography Berg W. et al JAMA 2008 Scaperrotto G. et al European Radiology 2008 Automated Breast Ultrasound A new way for Austria Decentralized program with qualified radiologists Centralized invitation of women from 45y to 69y Immediate Ultrasound in dense breast QM (technique, teaching, documentation) Breast Cancer Screening HIGH- RISK Patients American Cancer Society April 2008

5 M. 43a., MG: 1, US: 1, MRT: 5; IDC MG: 1, US: 1, MRT: 5; IDC Sensitivity MRI 82% MG 40% US 36% Specificity 90% 98% 95% SCREENING WITH MRI OF THE BREAST Intensity Enhancement Tumor 100 H. Tissue Contra. Lat Time in Seconds

6 P4 Medicine in Breast Imaging PREVENT BREAST CANCER (Lifestyle factors) Preventive: Need for less imaging & reduced ionizing radiation & less costs No Alcohol Sports Healthy food 3 x 60min workout / week: 50% reduction in BCA mortality ALARA: with Digital MG Breast Density & BCA-Risk Dosereduction: 75% PD: 1.63 mgy PD: 0.34 mgy Riedl C et al, Invest. Radiology 2006 Boyd et al, NEJM 2007 Boyd et al, Cancer Epidemiol Biomarkers Prev 1998 Breast Density & BCA CANCER-GROUP Up to 63% of breast density may be attributable to hereditary factors CONTROL Pinker et al, RSNA 2010

7 Breast Density Assessment MRI based pure volumetric Dixon Technique for breast MRI density measurements Fat Water Pinker, Helbich et al. RSNA 2011 Breast Density Assessment MRI based pure volumetric Dixon Technique for breast MRI density measurements Example of the algorithm's results: left: fat: mm 3 ( 56% ) tissue: mm 3 ( 44% ) volume: mm 3 right: fat: mm 3 ( 55% ) tissue: mm 3 ( 45% ) volume: mm 3 P4 Medicine in Breast Imaging Personalized: Right care to the right patient at the right time: improves outcome & minimize costs Pinker, Helbich et al. RSNA 2011 Global Language EUSOMA - Guidelines BI-RAD System: 1: negative 2: benign 3: probably benign (cancer rate < 2 %) 4: suspicious 5: highly suggestive of malignancy 6: verified malignancy Intervention In 90% BIRADS 4 or 5 lesions needle biopsy should be performed prior to open breast biopsy EUSOMA 2001

8 US-guided Core-Needle Biopsy CORE BREAST BIOPSY false negative rate low, alternative to open biopsy Stereotactic 1) -3 % US / MRI-guided 2) -3 % 5 core samples! 1) Pfarl et al. AJR ) Schüller et al. Radiology 2009 BREAST BIOPSY: COSTS CORE BREAST BIOPSY Diagnostic procedure and NOT a therapeutic one BUT Gruber, Helbich et al. EJR 2010 Reiner C, Helbich T et al. European Radiology 2009 Breast Lesion Excision System (Intact ) MRI-g Focused US Gianfelice D et al. Radiology 2003

9 GENOMIC TESTS GENEXPRESSION gene signatures Based on critical molecular pathways in BCA To evaluate risk MammaPrint, Rotterdam Signature, Oncotype GENEXPRESSIONS PROFILE, 7 Subtypen Kao et al. Cancer 2011 BLOOD TEST Personalized Blood Tests for Cancer Using Whole Genome Sequencing ScienceDaily (Feb. 19, 2010) Scientists at the Johns Hopkins Kimmel Cancer Center have used data from the whole genome sequencing of cancer patients to develop individualized blood tests they believe can help physicians tailor patients' treatments. The genome-based blood tests, believed to be the first of their kind, may be used to monitor tumor levels after therapy and determine cancer recurrence. Functional Capabilities of Cancer Development Cancers have acquired same set of functional capabilities during their development with different strategies Hanahan et al, Cell 2000 Multiparametric MRI MRI: Morphology / Angiogenesis Angiogenesis-map MRI Morphology & Angiogenesis MRSI metabolism DWI molecular capabilities Intensity Enhancement Tumor 100 H. Tissue Contra. Lat Time in Seconds

10 Diffusion-weighted MR (~ 2:30 Min) ADC threshold of mm 2 /sec Sensitivity 96% Specificity 94% MRI 24% (9 FP) DWI 5 % (2 FP) MRSI 19 % (7 FP) Multiparametric MRI Multiparametric-MRI 11% (4 FP) Obviates unnecessary breast biopsies in 89% of benign lesions Bogner et al., Radiology 2009 Pinker et al., RSNA 2011 PRE CHEMO POST CHEMO Responder Non-Responder FDG-PET of the Breast DIRECT Target 68 Ga-DOTA-F(ab') 2 -herceptin most common used most validated new tracers: 1. Proliferation 2. Hypoxia 3. Apoptosis 4. Angiogenesis 5. Receptor status Assess biochemical alterations in diseases 17-AAG control before 2d after before 2d after Schirrmeister et al. EJNM 2001; Goerres et al. ER 2003; Avril et al. Rad Clin N Am 2007 Smith-Jones PM S., MSKCC, New York

11 P4 Medicine in Breast Imaging Participatory: PERSONAL INVITATION FOR SCREENING Need for more interaction between radiologists and patients BEST INTERACTION WITH PATIENTS AMONG RADIOLOGISTS! TEAM APPROACH US-guided Core-Breast Biopsy TEAM: RADIOLOGEN RTA / MTF Datenverwaltung Risikoberatung P4 - BREAST IMAGING with High Quality Operateur Plastische Chirurgie TEAMGEIST Radio-Onkologen Palliative Versorgung Patients will acknowledge our effort Pflegepersonal Physiotherapie PATIENT Radiologen RTA/ MTF Pathologen Psychosozialer Dienst MRI-PET X OPTICAL

12 P4 Medicine in Breast Imaging Predictive: Screening tools for early and accurate diagnosis: leads to early intervention & less chronic disease Personalized: Right care to the right patient at the right time: improves outcome & minimize costs Preemptive / Preventive: Need for less imaging & reduced ionizing radiation Participatory: Need for more interaction between radiologists and ti t