Breast Imaging: Multidisciplinary Approach. Madelene Lewis, MD Assistant Professor Associate Program Director Medical University of South Carolina

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1 Breast Imaging: Multidisciplinary Approach Madelene Lewis, MD Assistant Professor Associate Program Director Medical University of South Carolina

2 No Disclosures

3 Objectives Discuss a multidisciplinary breast clinic model Review common multidisciplinary features of breast care including Cancer subtypes Extent of disease Management of the axilla Margin assessment Neoadjuvant Chemotherapy Monitoring for Recurrence

4 What is a multidisciplinary team? Group of health care members in different disciplines, each providing specific services to the patient with the aim of ensuring that the patient receives optimum care and support

5 Multidisciplinary Approach Team of Breast Experts Radiology Pathology Surgery Radiation Oncology Medical Oncology Plastic Surgery Genetic Counselors Nurse Coordinators and Navigators Survivorship

6 Multidisciplinary Breast Clinic

7 Effectiveness of Multidisciplinary Cancer Treatment Increases patient satisfaction Reduces time between diagnosis and initiation of treatment Improved outcomes including survival and reduced variation in survival among hospitals Kessen E BMJ 2012 Abdulrahman Pan Afr Med J 2011

8 The MUSC Model Wednesday AM: Concordance conference Thursday AM: Multidisciplinary tumor board Thursday following TB: Multidisciplinary clinic

9 Cases

10 42 yo female screening mammogram

11 US Biopsy Invasive Ductal Carcinoma ER+, PR+, HER2-

12 Subtype Molecular/Genetic Characteristics Prevalence Clinical Characteristics Luminal A Luminal B ER+ and/or PR+, HER2-, low Ki67 ER+ and/or PR+, HER2+ (or HER2- with high Ki67) 40% Slow growing Less aggressive Low recurrence High survival Best prognosis of all subtypes Respond to endocrine therapy 10-20% High proliferation rates Worse prognosis than Luminal A Respond to endocrine therapy HER2 over expressing ER-, PR-, positive for human epidermal growth factor receptor 2 (EGFR2) protein 10% Tend to grow and spread more aggressively More likely to be high grade and node positive Poor short term survival Targeted therapies exist TNBC ER-, PR-, HER % Younger age at diagnosis High histologic grade Higher rates of distant recurrence after surgery Poor short-term prognosis Lack targeted therapy Andersen, Breast CA Res Trt 2014

13 Systemic Treatment Goal to prevent distant (metastatic) recurrence Chemotherapy Works in all subtypes Best for TNBC, HER2+ Endocrine Therapy >5years if hormone receptor positive Tamoxifen: selective estrogen response modifier (SERM) Aromatase inhibitors: estrogen synthesis blockers (post menopausal only)

14 36 yo female with left upper outer quadrant palpable mass

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18 US Biopsies IDC-Triple Negative Metastatic Intramammary Lymph Node

19 Managing the Axilla US primary modality for evaluating the axilla Morphology most important Imaging not sufficient in excluding malignancy Sentinel node biopsy in patients with invasive cancer despite absence of abnormal nodes on imaging

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21 Normal

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25 Axilla SLN metastases <0.2mm-isolated tumor cells (ITCs) pn0(i+) 0.2mm-2mm micrometastases N1(mi) >2mm macrometastases N1

26 Assessing Extent of Disease

27 47 year old with palpable mass

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29 Nipple Involvement

30 Muscle Invasion

31 Abuts no invasion

32 Metastasis to Latissimus Dorsi

33 Skin Involvement

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38 Biopsy proven cancer MRI detected contralateral cancer

39 Osseous Metastatic Disease

40 56 year old screening mammogram

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42 US Bx-IDC ER-, PR-, HER2+

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45 Margin Assessment Negative No tumor on ink Tumor >1 or 2 mm from ink Close Tumor <1 or 2 mm of ink Positive Tumor at inked margin

46 Post Operative Imaging for Assessing Adequacy of Resection Ultrasound Not demonstrated to be of value Specimen x-ray after localization Post-operative, pre-radiation mammogram Can be helpful in cases with calcifications MRI

47 Evaluation of the Specimen Radiograph Lesion present? Wire/seed/clip present? Location of lesion within specimen

48 Specimen Radiograph for Margin Assessment Not reliable for judging adequacy of excision More accurate when it suggests incomplete excision

49 MRI for Post-Operative Margin Assessment May be useful when the extent of the index tumor is in question and margins are close or positive

50 MRI for Post-Operative Margin Assessment Normal post-surgical appearance Thin rim of enhancement around surgical cavity Minimal residual at margins cannot be excluded Negative MRI does not preclude the need for reexcision Abnormal appearance Thick, irregular, nodular or extensive non-mass enhancement False positives due to inflammation Tissue should be obtained before changing therapy

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52 NAC and MRI MRI more accurate in determining residual disease than PE, mammo, US Define pattern of residual tumor as contiguous or scattered-leads to better surgical selection Rosen AJR 2003 Yeh AJR 2005

53 NAC

54 NAC

55 BIRADS?

56 Monitoring for Recurrence MUSC Imaging Algorithm 6 months after completion of XRT Spot compression view of lumpectomy bed Annual Mammogram

57 Timing of Recurrence Recurrence rare within first 2 years BCT changes stable at 2-3 years after XRT Recurrences usually 2-6 years post BCT Recurrences >10 years usually represent new cancer and not treatment failure

58 Typical Findings with BCT Mass/seroma Architectural distortion Fat necrosis Trabecular edema Skin thickening

59 Post BCT: Seroma

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61 Post BCT: Architectural Distortion

62 6 months post XRT 2.5 years post treatment

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64 Post BCT: Calcifications

65 Post Lumpectomy

66 Fat Necrosis

67 Post BCT: Edema, Skin Thickening

68 Site of Recurrence 2% 2% 23% 10% 63% Same site Same quadrant Remote Radiation Induced Diffuse

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72 Post Lumpectomy

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74 1 year later

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76 Current Prior

77 Recurrence at Lumpectomy Site

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82 US Bx: Metastatic Lymph Node

83 Conclusion Multidisciplinary clinics improve patient care, satisfaction and outcomes Margin assessment best by pathology Radiologists play a critical role in assessing extent of disease MRI is the best modality for assessing response to NAC Recurrence usually occurs 2-6 years out and majority are in the surgical bed