Contrast Enhanced Spectral Mammography (CESM) in Cancer Staging

Transcription

1 Contrast Enhanced Spectral Mammography (CESM) in Cancer Staging Carrie Rochman,MD Assistant Professor,Breast Imaging UVA Dept of Radiology and Medical Imaging

2 Disclosures Research Agreement and Funding; Theraclion, Inc.

3 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

4 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

5 What is CESM? IV injection of low osmolar agents similar to those used for CT Dual energy mammogram performed after administration of IV iodinated contrast Two exposures at low and high energy Result = 2 mammographic images in each view Total imaging time 6-10 minutes

6 What is CESM? Low Energy (LE) image Similar to standard FFDM Provides morphologic information Recombined image Provides physiologic information about areas of increased blood flow

7 Normal CESM

8 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

9 Appearance of Breast Cancer on CESM - Mass L CC L CC L MLO L MLO Path = IDC

10 Cancer on CESM Non Mass Enhancement Path = DCIS

11 CESM vs. Digital Mammography Several studies comparing CESM to standard FFDM Improved sensitivity and specificity of CESM in the detection of breast cancer, especially in pre-menopausal women and women with dense breasts.

12 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Screening Recalls and Symptomatic Patients Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

13 CESM for Screening Recalls CESM (Black bar) improved sensitivity, specificity, PPV, and NPV when compared to FFDM (grey bar) CESM was especially useful in downgrading mammographic lesions based on false-positive recalls, as well as decreasing the need for 6-12 month follow up imaging for inconclusive findings (i.e., BI-RADS 3 findings) Lobbes, M. B. I., Lalji, U., Houwers, J., Nijssen, E. C., Nelemans, P. J., van Roozendaal, L., et al. (2014). Contrastenhanced spectral mammography in patients referred from the breast cancer screening programme. European Radiology, 24(7),

14 CESM for Screening Recalls CESM increased diagnostic accuracy with improved sensitivity 96.9 % (+3.9 %), specificity 69.7 % (+33.8 %) and area under the ROC curve (+0.188). Lalji, U. C., Houben, I. P. L., Prevos, R., Gommers, S., van Goethem, M., Vanwetswinkel, S., et al. (2016). Contrastenhanced spectral mammography in recalls from the dutch breast cancer screening program: Validation of results in a large multireader, multicase study. European Radiology, 26(12),

15 70 y.o. Baseline Exam

16 Initial Imaging for Screening Recall CESM

17 CESM vs. FFDM for Symptomatic Patients Retrospective reader studies comparing CESM over standard mammography in symptomatic patients with suspicious palpable abnormalities ROC analysis performance of CESM over FFDM, with area under the curve of 0.93 versus 0.83 (p<0.025). Increased Sensitivity (95% versus 84%, p<0.025) Increased Specificity (81% versus 63%, p<0.025) Tumour size estimation at CESM was significantly more accurate than FFDM alone, the latter tending to undersize lesions. S.L. Tennant, J.J. James, E.J. Cornford, et al.contrast-enhanced spectral mammography improves diagnostic accuracy in the symptomatic setting Clin Radiol, 71 (11) (2016), pp

18 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

19 Tumor Size: Comparison of CESM to FFDM and US Comparison of mean tumor size estimation on CESM, FFDM, and US vs. pathology gold standard Improved assessment of tumor size compared to FFDM and US C. Dromain, F. Thibault, S. Muller, et al.dual-energy contrast-enhanced digital mammography: initial clinical results Eur Radiol, 21 (2011), pp K.S. Blum, C. Rubbert, B. Mathys, et al.use of contrast-enhanced spectral mammography for intramammary cancer staging: preliminary results Acad Radiol, 21 (2014), pp

20 Tumor size: Comparison of CESM to MRI Prospective study 80 cases (61 IDC, 13 ILC, 6 pure DCIS) Breast cancer was visible in 66/80 MG, 80/80 CESM, and 77/79 MRI examinations No significant difference was found between lesion size measurement on MRI and CESM compared with histopathology. EM Fallenberg, C Dromain, F Diekmann, et al.contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size Eur Radiol, 24 (2014), pp

21 Tumor Size: Ill Defined Palpable Breast Mass Pt is on Dialysis: Unable to Have MRI

22 Tumor Size

23 Multifocal Breast Cancer R CC Low Energy Image R CC Recombined Image R MLO Low Energy Image R MLO Recombined Image

24 Surgical Planning L CC FFDM Image 72 y/o female with a screening detected 19 mm high density, irregular mass with indistinct margins Biopsy at an outside facility demonstrated invasive ductal carcinoma.

25 Case Extent 3 ( of Disease: Surgical Planning L CC Low Energy Image L CC Recombined Image CESM was peformed to better assess tumor size. Biopsy was subsequently performed, demonstrating multifocal IDC. CESM was able to better determine extent of disease and directed the location for staging biopsy. The patient was able to undergo breast conserving therapy.

26 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

27 Detection of Contralateral Disease Synchronous breast cancer occurs in 1-3% of newly diagnosed breast cancers Lobular cancer in the index breast, family history of breast cancer, young age at diagnosis of first cancer and BRCA mutations are important risk factors that are known to be at increased risk for BBC Padmanabhan N, Subramanyan A, Radhakrishna S. Synchronous Bilateral Breast Cancers. J Clin Diagn Res. 2015;9(9):XC05-XC08. McCaul KA. Bilateral breast cancer incidence and survival. [PhD thesis]. North Terrace, ADELAIDE SA 5005: University of Adelaide; Available from: University of Adelaide, School of Population Health and Clinical Practice, Library E-Reserve

28 Contralateral Malignancy R CC Low Energy Image R CC Recombined Image R MLO Low Energy Image R MLO Recombined Image

29 Prior Normal Left Mammogram with DBT Pathology showed ILC

30 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

31 Role of CESM in Cancer Follow Up Response to Neoadjuvant Therapy Morphology of tumor with LE image Physiology of contrast enhancement CESM and MRI lesion size were highly correlated CESM at least as reliable as MRI in assessing the response to NAC Iotti V1, et al. Contrast-enhanced spectral mammography in neoadjuvant chemotherapy monitoring: a comparison with breast magnetic resonance imaging. Breast Cancer Res Sep 11;19(1):106. doi: /s

32 Monitoring Response to Neoadjuvant Therapy R MLO Recombined CESM R MLO Low Energy CESM R MLO Recombined CESM R MLO Low Energy CESM Prior Current

33 Follow Up after BCT Dense or heterogeneously dense High risk patients when MRI is no longer covered by insurance Previous malignancy mammographically occult R CC CESM R CC

34 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

35 Limitations of CESM Contraindications for CESM No biopsy ability Allergy to intravenous iodinated contrast Acute kidney injury (increase in serum Cr by >0.3 mg/dl within 48 hours or increase of >1.5 times baseline within prior 7 days) Chronic renal failure (GFR <30), unless patient is on regular hemodialysis Breast Implants False Positives False Negatives

36 Limitations of CESM False Positives Benign Lesions Fibroadenomas are the most common benign lesion that demonstrate enhancement on CESM Papillomas, hamartomas, intra-mammary lymph nodes, fat necrosis, and complicated cysts can also enhance

37 Bilateral Breast Cancer with Incidental False Positive Fibroadenoma R MLO L MLO R MLO L MLO

38 False Positive Papilloma

39 False Negatvie CESM Screening detected calcs. On CESM no enhancement is seen in the area of the calcifications. Path = intermediate grade DCIS. The absence of enhancement does not deter biopsy of suspicious imaging findings seen on the low energy CESM images.

40 R CC Recombined Image R MLO Recombined Image False Negative CESM Path = Well-differentiated IDC with lobular features. R CC Low Energy Image R MLO Low Energy Image

41 CESM False Negative Likely due to masking effect of marked background enhancement

42 Objectives Imaging technique for CESM Appearance of breast cancer on CESM Role of CESM in cancer staging Primary detection Ipsilateral Extent of disease Detection of contralateral disease Role of CESM in cancer follow up Limitations of CESM

43 References Ali-Mucheru, M., Pockaj, B., Patel, B., Pizzitola, V., Wasif, N., Stucky, C. C., et al. (2016). Contrast-enhanced digital mammography in the surgical management of breast cancer. Annals of Surgical Oncology, 23(Suppl 5), Bhimani, C., Matta, D., Roth, R. G., Liao, L., Tinney, E., Brill, K., et al. (2017). Contrast-enhanced spectral mammography: Technique, indications, and clinical applications. Academic Radiology, 24(1), Cheung, Y., Lin, Y., Wan, Y., Yeow, K., Huang, P., Lo, Y., et al. (2014). Diagnostic performance of dual-energy contrast-enhanced subtracted mammography in dense breasts compared to mammography alone: Interobserver blind-reading analysis. European Radiology, 24(10), Covington, M. F., Pizzitola, V. J., Lorans, R., Pockaj, B. A., Northfelt, D. W., Appleton, C. M., et al. (2018). The future of contrast-enhanced mammography. AJR.American Journal of Roentgenology, 210(2), Dromain, C., Thibault, F., Muller, S., Rimareix, F., Delaloge, S., Tardivon, A., et al. (2011). Dual-energy contrast-enhanced digital mammography: Initial clinical results. European Radiology, 21(3), Fallenberg, E. M., Dromain, C., Diekmann, F., Engelken, F., Krohn, M., Singh, J. M., et al. (2014). Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size.european Radiology, 24(1), Helal, M. H., Mansour, S. M., Zaglol, M., Salaleldin, L. A., Nada, O. M., & Haggag, M. A. (2017). Staging of breast cancer and the advanced applications of digital mammogram: What the physician needs to know? The British Journal of Radiology, 90(1071), Iotti, V., Ravaioli, S., Vacondio, R., Coriani, C., Caffarri, S., Sghedoni, R., et al. (2017). Contrast-enhanced spectral mammography in neoadjuvant chemotherapy monitoring: A comparison with breast magnetic resonance imaging.breast Cancer Research : BCR, 19(1), James, J. J., & Tennant, S. L. (2018). Contrast-enhanced spectral mammography (CESM) doi: Jochelson, M. S., Dershaw, D. D., Sung, J. S., Heerdt, A. S., Thornton, C., Moskowitz, C. S., et al. (2013). Bilateral contrast-enhanced dual-energy digital mammography: Feasibility and comparison with conventional digital mammography and MR imaging in women with known breast carcinoma. Radiology, 266(3), Lalji, U. C., Houben, I. P. L., Prevos, R., Gommers, S., van Goethem, M., Vanwetswinkel, S., et al. (2016). Contrast-enhanced spectral mammography in recalls from the dutch breast cancer screening program: Validation of results in a large multireader, multicase study. European Radiology, 26(12), Lee-Felker, S. A., Tekchandani, L., Thomas, M., Gupta, E., Andrews-Tang, D., Roth, A., et al. (2017). Newly diagnosed breast cancer: Comparison of contrast-enhanced spectral mammography and breast MR imaging in the evaluation of extent of disease. Radiology, 285(2), Lewin, J. M., Isaacs, P. K., Vance, V., & Larke, F. J. (2003). Dual-energy contrast-enhanced digital subtraction mammography: Feasibility. Radiology, 229(1), Li, L., Roth, R., Germaine, P., Ren, S., Lee, M., Hunter, K., et al. (2017). Contrast-enhanced spectral mammography (CESM) versus breast magnetic resonance imaging (MRI): A retrospective comparison in 66 breast lesions.diagnostic and Interventional Imaging, 98(2), Lobbes, M. B. I., Smidt, M. L., Houwers, J., Tjan-Heijnen, V. C., & Wildberger, J. E. (2013). Contrast enhanced mammography: Techniques, current results, and potential indications doi: " Lobbes, M. B. I., Lalji, U., Houwers, J., Nijssen, E. C., Nelemans, P. J., van Roozendaal, L., et al. (2014). Contrast-enhanced spectral mammography in patients referred from the breast cancer screening programme. European Radiology, 24(7), Luczynska, E., Heinze-Paluchowska, S., Dyczek, S., Blecharz, P., Rys, J., & Reinfuss, M. (2014). Contrast-enhanced spectral mammography: Comparison with conventional mammography and histopathology in 152 women. Korean Journal of Radiology, 15(6), Patel, B. K., Garza, S. A., Eversman, S., Lopez-Alvarez, Y., Kosiorek, H., & Pockaj, B. A. (2017). Assessing tumor extent on contrast-enhanced spectral mammography versus fullfield digital mammography and ultrasound. Clinical Imaging, 46, Patel, B. K., Lobbes, M. B. I., & Lewin, J. (2018). Contrast enhanced spectral mammography: A review. Seminars in Ultrasound, CT, and MR, 39(1), Patel, B. K., Hilal, T., Covington, M., Zhang, N., Kosiorek, H. E., Lobbes, M., et al. (2018). Contrast-enhanced spectral mammography is comparable to MRI in the assessment of residual breast cancer following neoadjuvant systemic therapy. Annals of Surgical Oncology, 25(5), Tennant, S. L., James, J. J., Cornford, E. J., Chen, Y., Burrell, H. C., Hamilton, L. J., et al. (2016). Contrast-enhanced spectral mammography improves diagnostic accuracy in the symptomatic setting doi:

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