Updates in Mammography. Dr. Yang Faridah A. Aziz Department of Biomedical Imaging University Malaya Medical Centre

Transcription

1 Updates in Mammography Dr. Yang Faridah A. Aziz Department of Biomedical Imaging University Malaya Medical Centre

2 Updates in Mammography Breast Imaging Dr. Yang Faridah A. Aziz Department of Biomedical Imaging University Malaya Medical Centre

3 Updates in Breast Imaging Digital Mammography including CAD Tomosynthesis Contrast-enhanced Mammography MR breast imaging

4 Breast Disease Breast Disease Breast carcinoma is the commonest cancer in Malaysian women in every race 3738 new cases every year A woman in Malaysia has a 1 in 20 chance of developing breast cancer in her lifetime National Cancer Registry Malaysia report 2003

5 Breast Disease Breast Disease Statistics from National Cancer Registry, 2002 & Charts from

6 Mammography through the years Mammography is shown to be effective in reducing breast cancer mortality through early detection 1 Breast imaging started in 1913 by Albert Salomon Mammography started in the 1960s 2 In 1969, the first x-ray units dedicated to breast imaging were available 2 By 1976, mammography as a screening device became standard practice and its value in the diagnosis of breast carcinoma was recognised 1. Tabar L et al. Beyond randomized controlled trials: organized mammography screening substantially reduces breast cancer mortality. Cancer 2001; 91:

7 Mammography through the years Screen-film mammography (SFM) is the technology of choice Personnel involved are well-trained in this method Low cost and high spatial resolution Ongeval V et al. Current status of digital mammography for screening and diagnosis of breast cancer. Curr opin intern med 2007; 6(1):

8 Mammography through the years In general radiology, transition to digital technology began two decades ago Digital mammography was first introduced in stereotactic biopsy Digital mammography was slow due to difficulty to produce full-field digital detectors In 2005, the first digital mammography was approved Ongeval V et al. Current status of digital mammography for screening and diagnosis of breast cancer. Curr opin intern med 2007; 6(1):

9 Digital vs SFM Digital vs SFM Detection of breast lesion Workflow processes Image quality including image postprocessing Image archival and retrieval

10 Digital vs SFM Digital vs SFM Detection of breast lesion Workflow processes Image quality including image postprocessing Image archival and retrieval

11 Detection of breast lesion Detection of breast lesion Breast is a difficult organ to imaged Breast density ranges from dense (75% or more of breast compose of glandular tissue) to fatty Sensitivity of detection of carcinoma is 62.9% in dense breast compared to 87% in fatty breast 1 1. Carney PA et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003;138(3):

12 Image quality Image quality Fatty backgound

13 Image quality Image quality Moderately dense

14 Image quality Image quality Dense breast

15 Lesion detection vs breast density Lesion detection vs breast density Women with dense tissue have a four to six times higher risk of breast cancer compared to women with little or no dense tissue Masking of existing lesion by overlying breast tissue Boyd NF et al. Mammographic Density and the Risk and Detection of Breast Cancer. New England Journal of Medicine 2007; 356(3):

16 Digital vs SFM Digital vs SFM Overall diagnostic accuracy of digital and film mammography for breast cancer detection is similar Digital is more accurate in: Women under 50 Women with dense breast Premenopausal or perimenopausal women Due to wide dynamic range of digital, able to display contrasting regions without compromising resolution Pisano ED et al. Diagnostic Performance of Digital versus Film Mammography for Breast-Cancer Screening. New England Journal of Medicine 2005; 353(17):

17 Detection of breast lesion: calcification SFM boasts a high spatial resolution good for detection of microcalcification DM is limited by pixel size However the high contrast resolution of DM shows more calcification compared to SFM increases the ability to characterize calcification better Kim HH, Pisano ED, et al. Comparison of calcification specificity in digital mammography using softcopy display versus screen-film mammography. AJR 2006; 187(1):47-50

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19 Clustered microcalcification Biopsy: Ductal carcinoma in situ

20 Detection of breast lesion Detection of breast lesion DM also allows for use of software such as computer-aided detection CAD serves as a second reader in a screening mammogram programme

21 Computer aided diagnosis Computer aided diagnosis Diagnosis made by a radiologist taking into account the computer output as a second opinion Causes of missed cancers Poor image quality training of radiographers and QA Misinterpretation training of radiologists Oversight second reader/cad Used mainly in screening mammography Courtesy of Siemens

22 Digital vs SFM Digital vs SFM Detection of breast lesion Workflow processes Image quality including image postprocessing Image archival and retrieval

23 Digital vs SFM Digital vs SFM Reliance on personnel Problems with film processing e.g. artifacts

24 Digital vs SFM Digital vs SFM

25 Digital Imaging Digital Imaging Workflow of different modalities Time (mins) Interpretation and results Processing time Exposure time SFM 1 CRM 2 DM3 Modalities Ranganathan S, Y Faridah, KH Ng. Moving into the digital era: a novel experience with the first full-field digital mammography system in Malaysia. Singapore Med J 2007; 48(9):

26 Workflow processes Workflow processes A 45% reduction in the time taken to perform and process images using DM compared to SFM DM is also useful in stereotactic biopsy and hookwire localisation Hard-copy images of DM is consistent without presence of artifacts Ranganathan S, Y Faridah, KH Ng. Moving into the digital era: a novel experience with the first full-field digital mammography system in Malaysia. Singapore Med J 2007; 48(9):

27 Workflow processes - biopsy Workflow processes - biopsy Use of digital system during biopsy decreases the overall time of procedure as images do not need to be processed for needle placement

28 Digital vs SFM Digital vs SFM Detection of breast lesion Workflow processes Image quality including image post-processing Image archival and retrieval

29 Digital vs SFM Image quality Digital vs SFM Image quality DM is able to manipulate digital information Repeat rate with DM is low DM can change image contrast, zoom and magnify Delineates subcutaneous skin better than SFM However no amount of image manipulation could compensate for a badly taken mammogram!

30 Mammogram mass Mammogram mass benign Sebaceous cyst

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32 HPE invasive ductal carcinoma

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34 Biopsy: Mucinous carcinoma

35 Mammogram - mass Mammogram - mass Carcinoma

36 Digital vs SFM Digital vs SFM Detection of breast lesion Workflow processes Image quality including image postprocessing Image archival and retrieval

37 Digital vs SFM Digital vs SFM

38 Limitation of space

39 MAMMOGRAM FILMS FILM FILM MORE FILM Workflow in a Radiology department with SFM Limited storage Missing films Labour intensive Degradation of films RADIOLOGY DEPARTMENT, WARDS, CLINIC, OTHER HOSPITALS

40 MAMMOGRAPHY Workflow in a Radiology department with Digital

41 MAMMOGRAMS P A C S Radiology Dept Clinics Wards Other hospitals

42 Digital Mammography: in summary Digital Mammography: in summary Detection of breast lesion CAD Work-flow process Image quality Image archival Cost Overall sensitivity in screening for breast lesion Accuracy in dense breast Detection of microcalcification Use of software e.g. CAD Processing time Reporting time Ability to manipulate image Consistency of hard-copy image Subcutaneous tissue delineation Image archival and retrieval Cost, cost, cost! DM = SFM DM > SFM DM > SFM DM >> SFM DM >> SFM DM < SFM initially if do soft-copy reporting DM yes, SFM no DM > SFM DM >> SFM DM >> SFM DM >>> SFM

43 Breast Tomosynthesis Breast Tomosynthesis Acquisition of multiple images during Tomo scan Displays the breast in slices Reduces tissue overlap Reduction in compression pressure Dose? Similar to one view mammogram Courtesy of Siemens

44 Breast Tomosynthesis Breast Tomosynthesis Courtesy of Hologic

45 Courtesy of Siemens

46 Courtesy of Siemens

47 Contrast-enhanced Mammography A pre-contrast mammogram is performed An iodine-based contrast media is injected Post-contrasted images are then acquired These images (pre-contrast and contrasted) are subtracted

48 Contrast enhanced Mammography Jong RA et al. Contrast Enhanced Digital Mammography. Radiology 2003; 228:

49 Breast MR Breast MR Has a high sensitivity in detecting breast lesion Has a high negative predictive value No radiation

50 Breast MR: Drawbacks Breast MR: Drawbacks Picks up benign lesion as well Gives rise to higher number of unneccesary biopsies Cost

51 Breast MR Breast MR Not used for general population screening Reserved for young women with high risk of breast carcinoma Performed also in women with suspected multiple breast carcinomas

52 Breast MR Breast MR Courtesy of GE

53 Breast MR Breast MR Static T1WI, T2WI, STIR Contrast-enhanced Dynamic contrast-enhanced Spectroscopy

54 Breast MR Breast MR Courtesy of GE

55 Breast MR Breast MR Courtesy of GE

56 Breast MR Breast MR Courtesy of GE

57 Breast MR Breast MR a b c Figure 1 (a) T1 pre contasted (b) Contrast-enhanced T1-WT FLASH 3D showing an ill defined lesion with irregular margin, features typical of a carcinoma (c) Fat suppressed MRI image revealed a smaller satellite lesion (arrow) close to it. (c) The enhancement curve was Type III with an early peak and delayed phase rapid washout. Histology revealed multifocal invasive ductal carcinoma. d

58 Breast MR - Spectroscopy Breast MR - Spectroscopy Courtesy of GE

59 Breast MR - Biopsy Breast MR - Biopsy Courtesy of GE

60 Conclusion Exiting developments in breast imaging mainly due to digital technology Multiple approach to image the breast Do not forget that NOTHING can compensate for an examination that is done badly Perform the best that you can every time!

61 THANK YOU