Tomosynthesis and breast imaging update. Dr Michael J Michell Consultant Radiologist King's College Hospital NHS Foundation Trust

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1 Tomosynthesis and breast imaging update Dr Michael J Michell Consultant Radiologist King's College Hospital NHS Foundation Trust

2 Breast imaging new technology

3 BREAST CANCER FLT PET shows different grades of tumour with the primary site Images courtesy of Wai Lup Wong, Paul Strickland Cancer Centre Mount Vernon

4 Breast imaging:application of new technology screening diagnosis/ assessment local staging axilla response to RX systemic disease XRM TOMO? ++ ++? CE-XRM?? US? CE-MRI F MRI MOL CT/PET ++ +

5 Digital Breast Tomosynthesis Technology Accuracy Diagnosis/assessment Screening

6 Limitations of 2D mammography 3D information projected onto 2D image plane superimposition of tissues Clinical effect - false positive cases screening recall - false negative cases interval cancers - mammographic features obscured diagnostic uncertainty understaging

7 DBT - technology Hologic dimensions - 15 deg - 15 proj Siemens innovation - 50 deg - 25 proj GE - 40 deg - 15 proj Sectra continuous IMS - 40 deg - non uniform sampling DBT radiation dose 2V = up to 5 mgy. FFDM 2V = 4 mgy

8 reconstructed images are displayed as 1mm slices for viewing singly or in cine mode number of slices varies according to breast thickness

9 Does DBT improve diagnostic accuracy?

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12 Accuracy of DBT recall from screening bilateral 2D + tomo (combo)mlo/cc Michell MJ et al, Clin Rad 2012; 67:

13 soft tissue lesions microcalcification Michell MJ et al Clin Rad 2012

14 DBT - technical developments tomo guided biopsy synthetic 2D contrast tomo combined imaging CAD

15 Tomosynthesis procedure - Case 2 Target

16 Synthetic 2D the information from the reconstructed tomo slices is used to produce a 2D image

17 DBT - synthetic 2D standard 2D synthetic 2D DBT

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20 2D synthetic 2D

21 Synthetic 2D combined with DBT has equivalent accuracy compared to FFDM + DBT Skaane P et al Radiology. 2014, Jan Zuley M et al Radiology.2014, Jan

22 Contrast Mammography images are courtesy of the following sites: Rose Medical Center, Denver, CO, USA Hôpital Privé d Antony, Antony, FR Kaohsiung Veterans General Hospital, Taiwan

23 2D CE2D Sub 3D Slice

24 Assessment of screen detected lesions Questions 1. is there a lesion? 2. where is it? 3. what is the risk of malignancy? 4. tumour size 5. unifocal/multifocal? 6. what further tests are needed?

25 1. is there a lesion?

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27 2. Where is the lesion?

28 3. what s the risk of malignancy?

29 Lesions changing appearances Circumscribed Mass Mammographic features viewed on DBT Spiculated mass Distortion Asymmetric Density None (no abnormality) Mammographic features viewed on FFDM Circumscribed mass Spiculated mass Distortion Asymmetric Density None (no abnormality) Total Iqbal A, Michell MJ et al RSNA 2011

30 adenolipoma fibroadenoma mucinous ca

31 Comparison of DBT with spot compression magnification views

32 spot compression Mag MLO DBT MLO

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34 Invasive lobular cancer

35 difficult diagnostic work up

36 Mag CC DBT CC

37 US = U1 MRI +ve DBT guided NLB Gd 2 IDC

38 Non specific asymmetric density

39 Final diagnosis high grade DCIS

40 Are all tumours visible on DBT Palpable mass LT breast - recalled from screening Irregular mass on US CB = Gd 3 IDC

41 Microcalcification

42 King s study:dbt vs spot compression mag views Clin Rad, accepted for publication lesions in 342 patients 104 malignant 82 benign 169 normal 7 radiologists standard + DBT vs standard + Mag DBT vs supplemental views for evaluation of non calcified lesions 217 lesions, 72 cancers AUC DBT = 0.87 suppl views = 0.83 p<.001 Zuley M, et al Radiology:266 Jan 2013

43 4. Measurement of tumour size Iqbal A, Michell MJ et al, RSNA 2013

44 Tumour size - Invasive Ductal Carcinoma DBT FFDM US Invasive Ductal Carcinoma, n = (0.551 to 0.759) (0.471to 0.711) ( ) Values are presented as CCC [rho_c, 95% CI]; CCC = Concordance correlation coefficient; Figures in parentheses are 95% confidence intervals.

45 Accuracy of tumour measurement correln coeff (a) MRI DBT DM US correln coeff (b) (a)luparia A, Mariscotti G et al Radiol Med (b)fornvik D, Zackrisson S et al Acta Radiol (3)

46 5. How many lesions?

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48 Tomosynthesis in diagnostic work up - advantages vs spot compression whole breast imaged easier positioning some cancers less visible on spot compression 3D information on lesion position DBT in two projections recommended USS still necessary for soft tissue lesions

49 Diagnostic work up/ assessment - current practice DBT for mammographic work up of soft tissue lesions fine focus mag views for microcalcification

50 DBT in screening specificity sensitivity combination of views case selection cost

51 DBT in screening trials - OSLO - ( P Skaane) - STORM - (S Ciatto ) - TOMMY - ( F Gilbert ) - MALMO - ( I Anderson )

52 OSLO Trial 36,000 women years Recruitment 11/10-12/12 Reading arms FFDM, FFDM + CAD, FFDM + DBT, synth 2D + DBT reading time - FFDM 45 secs - Combo 91 secs

53 OSLO Trial : Comparison of digital mammography alone and DM + tomosynthesis in a population based screening program P Skaane et al, Radiology, 2013 Jan 12,631 participants DM 77 cancers 6.1/1000 DM+DBT 112 cancers 8/ % increase in ca detection p =0.001 (95% CI ) 40% increase in invasive cancers p < Recall rate (prior to arbitration) DM 6.1% DM +DBT 5.3% 15% decrease recall rate p <0.001

54 7292 participants mean age 58 yrs Reading - 2D, 2D + 3D Cancer detection 2D 39 cancers 5.3/1000 (95% CI ) 2D + 3D 59 cancers 8.1/1000 (95% CI ) p< Recall Overall 395 (5.5%) Conditional recall 254 (3.5%) thelancet.com/oncology april

55 Oslo Trial screen detected cancers Grade DM DM+DBT Diff In situ low/int high Invasive

56 MALMO 2 Trial 1V DBT vs 2V 2D Siemens Preliminary results women 2V DM 1V DBT Cancer detection /1000 screened Recall rate % screened Zacrisson et al, ECR 2014

57 DBT in screening - expectations more screen detected cancers lower false positive recall rate? one reader BUT What about overdiagnosis

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60 Prospective RCT of tomosynthesis in screening Control group - standard 2V FFDM Study group - tomo + synthetic 2D Primary end point - interval cancer rates Sample size 30% improvement in cancer detection = 2-3/1000 UK interval cancer rate = 2.85 / mths?intervention might reduce interval ca rate to 1.85/1000 For 90% power need 50,000 per arm

61 Prospective RCT of tomosynthesis in screening Secondary endpoints cancer detection prognostic features recall rate one vs two readers economic analysis

62 Conclusion New imaging technology will make screening, diagnosis and treatment of breast disease more effective and more efficient Acknowledgements NHSBSP King s breast radiology team