DR AISHA A UMAR CHIEF CONSULTANT RADIOLOGIST NATIONAL HOSPITAL ABUJA.

Transcription

1 DR AISHA A UMAR CHIEF CONSULTANT RADIOLOGIST NATIONAL HOSPITAL ABUJA.

2 OUTLINE WHY DO WE IMAGE WHOM TO IMAGE WHEN TO IMAGE HOW TO IMAGE WHAT TO IMAGE WITH PERSONAL EXPERIENCE CONCLUSION/RECOMMENDATIONS

3 WHY DO WE IMAGE Breast cancer is life threatening Early detection remains the only defence.. Breast cancers that are smaller or non palpable are more treatable when detected Have a more favourable prognosis Stage I: 100% Stage IIA -IIB 81-92% Stage IIIA-B 54-67% Stage IV: 20% Based on 5 year survival, prognosis is as follows;

4 FINDINGS FROM STUDIES In a study by Ntekim et al, in 221 young women of 40 years and below in Ibadan, Nigeria Stage I disease was diagnosed in 5 (2%) stage II disease 29(13%) Stages III 102 (46%) Stage IV disease 85(39%) African Health Sciences Vol 9 No 4 December 2009

5 Ihekwaba found in his study of Breast cancer in Nigerian women. Stage I and Stage II- 17.3% Stage III % Stage IV % Br J Surg Aug;79(8):771-5.

6 OUTCOME OF SCREENING Howell et al in his review of Risk determination and prevention of breast cancer As a result of the introduction of screening and optimizing treatments, deaths from breast cancer have decreased by approximately one third over the past 20 years. Howell et al. Breast Cancer Research 2014, 16:446

7 WHOM TO IMAGE HIGH RISK PATIENTS Screening is recommended before 40 years In some cases 10 years earlier. Not before 25 years Hereditary breast cancer mutation gene Lower age of menarche, Late age of first pregnancy, Fewer pregnancies, Shorter or no periods of breastfeeding, and A later menopause. Other risk factors Increase in obesity, Alcohol consumption, Inactivity, or low physical activity Hormone replacement therapy (HRT).

8 Average risk patients Under 40 years Clinical breast examination Limited benefit for screening

9 Average risk patients Over 40 years of age Screening is recommended

10 WHEN TO IMAGE ASYMPTOMATIC SYMPTOMATIC

11 Indications for mammography in Ilorin by Akande et al 2015 Percent Screening Symptomatic Breast lump Breast pain Nipple discharge Breast swelling Axillary swelling Known cancer Niger Med J May- Jun; 56(3):

12 Guidelines for screening Various expert groups have different recommendations. A careful consideration must be given to the risks of developing breast cancer The benefits and harms of the screening intervention, The cost involved.

13 Expert groups in United states American Cancer Society (ACS), The American College of Obstetricians and Gynaecologists (ACOG), American College of Physicians (ACP), American College of Radiology (ACR), American Medical Association (AMA), The National Cancer Institute (NCI), National Comprehensive Cancer Network (NCCN), United States Preventive Services Task Force (USPSTF).

14 Expert groups guidelines Agreement Benefits of screening Disagreement When to start and end screening How often to screen What imaging modality to use for screening

15 US Preventive Services Task Force (USPSTF) breast cancer screening guidelines, 2009 No requirement for routine screening mammography in women aged years The decision to start regular, biennial screening mammography before age 50 years is individual Biennial screening mammography for women between age 50 and 74 years Insufficient current evidence to assess the additional benefits and harms of screening mammography in women aged 75 years or older

16 American college of Obstetrics and gynaecology guidelines ACOG recommend adherence to its current guidelines, Screening mammography every 1-2 years for women aged years Screening mammography every year for women aged 50 years or older

17 American college of Radiology (ACR) guidelines- High-risk women Women with a breast cancer (BRCA) gene mutation Their untested first- degree relatives, Women with a history of chest irradiation between the ages of 10-30, Women with 20% or greater lifetime risk of breast cancer

18 ACR guidelines for high risk women (1) Mammography screening Beginning at age years Or 10 years before age of first-degree relative with breast cancer Or 8 years after radiation therapy, Not before age of 25. (2)Breast MRI with and without contrast (3) Ultrasonography, where MRI is not available, or when patient cannot have MRI. Mammography and MRI are complementary examinations, both should be performed

19 ACR guidelines for intermediate risk women Women with personal history of breast cancer, Lobular neoplasia, Atypical ductal hyperplasia, Or 15%-20% lifetime risk of breast cancer. Mammography screening MRI breast without and with contrast Ultrasonography, where MRI is not available or where patient cannot have MRI.

20 ACR guide lines for average risk women Women with <15% lifetime risk of breast cancer, Breasts not dense. Screening from age 40 years, Mammography screening ONLY is appropriate MRI and Ultrasonography are not usually appropriate except in dense breast.

21 American Cancer society guidelines High risk women, similar to ACR guidelines, with complementary Mammography and Pre and post contrast MRI Intermediate risk women, only Mammography is indicated Average risk women, clinical breast examination with screening mammography.

22 HOW TO IMAGE By use of various radiological imaging modalities Mammography Ultrasound Magnetic resonance imaging Computed tomography X ray Used alone or in combination.

23 Mammography Film screen or digital Mammography. Patient is examined in the equipment room. Breast compressed Both breast are imaged in two standard views Cranio-caudal view Medio lateral oblique views Focal magnification views maybe required Images can be reviewed on either a PACS database Printed on films, to be viewed on a monitor

24 Ultrasonography Patient supine on a couch Use of high frequency linear probe >5.5Mhz Non ionising sound waves are introduced Ultrasound gel is used. Images acquired are displayed on the monitor Real time imaging Images obtained, can be stored, transferred and printed

25 MRI Using a high field MR Magnet of at least 1,0T With a additional appropriately sized surface breast coil, Patient is put in a prone position Both breast are examined at the same time Pre and post contrast studies are performed

26 Role of imaging Detection Follow up Post treatment Detection Mammography Ultrasound Magnetic resonance imaging

27 Follow up Follow up To assess size Number Extent Spread of lesion Ultrasound Mammography Computed tomography Magnetic resonance imaging

28 Post treatment Imaging To assess residual Recurrent disease Spread of disease Cure Mammography Ultrasound Computed tomography Magnetic resonance imaging

29 Mammography reports The goal of the radiologist is to determine whether the findings are normal, benign, or suspicious enough to warrant tissue sampling. First, breast symmetry, size, general density, and glandular distribution are observed. Next, a search for masses, densities, calcifications, architectural distortions, and associated findings is performed. For masses, the shape, margins, and density are analysed. The features of benign and malignant masses can be similar

30 WHAT TO IMAGE WITH ASYMPTOMATIC Screening based on high or average risk Age of patient SYMPTOMATIC Diagnostic imaging Mammography Ultrasound Magnetic resonance imaging Computed tomography

31 Mammography Mammography is a special type of low-dose x-ray imaging used to create detailed images of the breast. The best available population-based method to detect breast cancer. Mammography often reveals a lesion before it is palpable by CBE

32 Breast density Mammographic breast density pattern is a reflection of the relative proportion of radiolucent fat to the radiodense glandular epithelium and connective tissue. It is a known independent risk factor for developing breast cancer and can be used to predict who will develop breast cancer

33 Mammographic densities

34 Cost of imaging An estimated 48 million mammograms are performed each year in the United States. With a female population of about 162 million, this is equivalent to about 29% of female population. In Nigeria, with a female population of about 6.5million above 55 years (7.3% female population) At least 6.5million mammograms are required, with an estimated cost at N10,000/exam, equivalent to 65 billion naira/per year

35 Mammography outcomes Of all of the screening mammograms approximately 90% show no evidence of cancer. Only 2% of all screening mammograms are shown to be abnormal and require biopsy. Among cases referred for biopsy, approximately 80% of the abnormalities are benign, 20% are shown to be cancerous.

36 Limitations of Mammography Mammography sensitivity (67.8%) and specificity (75%) are not ideal. Mammography combined with clinical breast examination (CBE) slightly improves sensitivity (77.4%), with a modest reduction in specificity (72%). Sensitivity for breast cancer declines significantly with increasing breast density Mammography uses low-dose ionizing radiation, which may be harmful to the patient. Nevertheless, the benefits of mammography far outweigh the risks.

37 False positive and negative mammogram False positive, due to micro calcifications, some benign lesions, and summation of parenchyma 8-10% false negative Possible causes for missed breast cancers include ; Dense parenchyma obscuring a lesion, Poor positioning or technique, Perception error, Incorrect interpretation of a suspect finding, Subtle features of malignancy, and Slow growth of a lesion

38 Mammographic features Benign lesions Benign masses are often round or oval with circumscribed margins. Benign calcifications are usually large The presence of very low density fat in a lesion often indicates benign findings such as oil cysts, lipomas, galactoceles, and hamartomas.

39 Malignant features Malignant lesions tend to have irregular, indistinct, or spiculated margins. Malignancies tend to have density greater than that of the normal breast tissue. Micro calcifications

40 BI-RADS- Breast imaging reporting and data system The American College of Radiology (ACR) has established the Breast Imaging Reporting and Data System (BI-RADS) to guide the breast cancer diagnostic routine Lexicon of descriptors, A recommended reporting structure including final assessment categories with accompanying management recommendations, and A framework for data collection and auditing

41 BI-RADS CLASSIFICATION Inconclusive study BIRADS 0, Normal study - BIRADS 1 Benign findings BIRADS 2, Probably Benign findings BIRADS 3 Suspicious findings BIRADS 4 Highly suspicious findings BIRADS 5 Known Cancer BIRADS 6

42 Digital breast tomosynthesis DBT, also known as 3D mammography, uses the same compression views as 2D mammography and adds a 3D volume acquisition. Requires only a few additional seconds for each view, DBT has shown to be an advance over digital mammography, with higher cancer detection rates and fewer patient recalls for additional testing. (ACR statement)

43 ULTRASONOGRAPHY Ultrasonography uses non ionising radiation in imaging. A widely available and useful adjunct to mammography in the clinical setting. As a screening device, ultrasound is limited, notably by the failure to detect micro calcifications Poor specificity (34%). Differentiating solid and cystic masses. Also useful in the guidance of biopsies and therapeutic procedures

44 Role in cancer screening Kolb et al and Buchberger et al found that when performed carefully, ultrasonography may be useful in detecting occult breast cancer in dense breasts.

45 LESIONS ON ULTRASONOGRAPHY Suspicious lesion Benign lesion

46 Magnetic resonance imaging Complementary to mammography in high risk women The many advantages of breast MRI over conventional breast imaging for the detection of malignancy have become apparent with increasing clinical experience. No ionizing radiation All imaging planes possible Capability of imaging the entire breast volume and chest wall Superb 3-D lesion mapping with techniques such as maximum intensity projection (MIP) slab 3-D reconstruction Greater than 90% sensitivity to invasive carcinoma Detection of occult, multifocal, or residual malignancy Accurate size estimation for invasive carcinoma Good spatial resolution Ability to image regional lymph nodes (although accurate staging remains problematic)

47 MRI

48 Disadvantages of MRI High equipment and examination costs Limited scanner availability Need for the injection of a contrast agent No standard technique Poor throughput compared with that of ultrasonography or mammography Large number of images Long learning curve for interpretation False-positive enhancement in some benign tissues (limited specificity) Variable enhancement of in situ carcinoma A 5% incidence of slowly or poorly enhancing invasive carcinomas

49 Contraindications of MRI Contraindication to gadolinium-based contrast media ( allergy, pregnancy) Patient's inability to lie prone Marked kyphosis or kyphoscoliosis Marked obesity Extremely large breasts Severe claustrophobia

50 MRI sensitivity In a high-risk population, MRI and mammography combined have a higher sensitivity (92.7%) than ultrasound (US) and mammography combined (52%) Screening high-risk women with breast MRI is costeffective and the cost-effectiveness of screening MRI increases with increasing breast cancer risk. The American Cancer Society recommends screening breast MRI in certain high-risk women, and the ACR and Society of Breast Imaging endorse those recommendations

51 Personal Experience with breast screening colleague and friend diagnosed with breast cancer Radiology department, National hospital Abuja in collaboration with some NGO carries out cancer screening Zamfara well women, cancer screeing programme in collaboration with medical women association of Nigeria (MWAN) at Garki hospital, Abuja ( 100 women brought from Zamfara state) MWAN in collaboration with the Ministry of women affairs, organised a breast cancer awareness lecture at the National women centre, Abuja ( Over 300 women from across Nigeria) Radiology department, National hospital Abuja, organised a breast awareness symposium, with 155 participants, and delivered a free 10 units CME, for doctors using a multidisciplinary faculty Thereafter commenced Management approved free mammography screening for all female staff, of 40 years and above from March 2015 to date.

52 Mammography at National hospital Abuja Months J 38 0 strike F 6 5 M 28 0 fault A 31 0 fault M 14 4 J J 59 0 NMA A 15 7 NMA S O 22 0 JOHESU N 30 0 JOHESU D 10 0 JOHESU Total Challenges Frequents strikes Equipment faults Cost of examination No NHIS coverage for screening Lack of awareness Poor communication across teams Poor record keeping Lack of subspecialisation No dedicated breast management team

53 Mammography screening challenges in developing countries The World Health Organization has suggested that for a mammography screening program to be effective in the reduction of mortality, it needs to cover at least 70% of the population at risk. The Breast Health Global Initiative Guidelines recommend that a population-based screening mammography program should not be implemented until access to the basic cancer diagnosis and treatment resources is guaranteed

54 Cost effective strategy for LMIC Early diagnosis Promotion of the awareness of early signs and symptoms among the public, Education of first line health professionals Improved referral procedures to facilitate the prompt and adequate diagnosis and treatment of breast cancer in early stages

55 Down staging programme Training first-line health personnel in hospitals and rural clinics Raising public awareness through visual information and sensitization by trained health personnel. In Malaysia after 4 years of implementation, late-stage (Ⅲ and Ⅳ) breast cancer cases were reduced from 60% to 35%[

56 Conclusion Mammography is the only method of screening for breast cancer shown to decrease mortality. Annual screening mammography is recommended starting at: 1) age 40 for general population; 2) Age in some intermediate and high risk patients. OR 10 years earlier than the age of the affected relative at diagnosis in some other high risk patients. Mammography plus supplemental screening is recommended in selected high-risk populations and those with dense breast.

57 Recommendations Adoption and implementation of appropriate mammography screening guidelines, for Nigerian women in both high risk and average risk groups should be carried out. Adequate education of patients and health workers of the guidelines as well as early signs and syptoms Provision of appropriate framework for implementation of the guidelines through government support and private sector participation. Institution of an interdisciplinary breast cancer screening and management programme, with adequate provision of infrastructure, equipment, manpower, trained personnel and resources. Ensuring appropriate diagnosis and treatment of all patients, identified from the screening programme through health insurance and not fee for service.

58 THANK YOU