#46: DIGITAL TOMOSYNTHESIS: What is the Data Really Showing? TERMS (AKA) WHAT IS TOMOSYNTHESIS? 3/3/2014. Digital breast tomosynthesis =

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1 #46: DIGITAL TOMOSYNTHESIS: What is the Data Really Showing? January K. Lopez, MD Hoag Breast Care Center Newport Beach, CA Disclosures: None TERMS (AKA) Digital breast tomosynthesis = DBT Tomo 3D Full field digital mammography = FFDM DM 2D WHAT IS TOMOSYNTHESIS? X-ray tube swings during tomo Stationary breast platform 1

2 WHAT IS TOMOSYNTHESIS? X ray tube moves in an arc across the breast Arc of motion of x ray tube, showing individual exposures A series of low dose images are acquired from different angles Total dose approximately the same as one 2D mammogram Projection images are reconstructed into 1 mm slices Reconstructed Slices { Compression Paddle Compressed Breast Detector Housing WHY TOMOSYNTHESIS? Reason #1: SEE CANCER BETTER! WHY TOMOSYNTHESIS? Reason #2: Reduce superimposition artifact content/uploads/2013/01/optical_illusion_photography_01.jpg 2

3 WHY TOMOSYNTHESIS? Reason #3: Better characterize Benign/normal findings So what does the data show? THE DATA Reader studies Diagnostic studies Screening studies Population based studies 3

4 EARLY DATA Small pilot and retrospective studies Enriched data sets N , 513 Variable results EARLY DATA Retrospective studies favor 2D Most lesions initially detected by 2D Small N EARLY DATA (Rafferty, et al Radiology) Multicenter, multireader, prospective, enriched reader study 1192 women 3D + 2D vs. 2D alone 4

5 EARLY DATA (Rafferty, et al Radiology) Increased accuracy Decreased recall rate (6% 67%) 15%/22% SN for invasive CA Only 3% SN for in situ POPULATION BASED SCREENING TRIALS OSLO TOMOSYNTHESIS SCREENING TRIAL 1 st prospective large scale population based screening trial of DBT Compared 2D mammo to 2D + DBT (3D) Interim analysis 12,631 women screened (50 69 yo) Est. enrollment 25,000 Est. completion Sept 2015 Skaane P, et al. Comparison of Digital Mammography Alone and Digital Mammography Plus Tomosynthesis in a Populationbased Screening Program. Radiology Apr;267(1):

6 OSLO TOMOSYNTHESIS SCREENING TRIAL Statistically significant results: Increased cancer detection (27% overall) Increased invasive cancer detection (40%) Decreased false positive rates (15%) Could have bigger impact in US given low baseline recall rate in Norway (6%) OSLO TOMOSYNTHESIS SCREENING TRIAL No significant difference in DCIS detection cancer detection for all breast densities, esp Scattered (type 2) and Heterogeneous breasts (type 3) MALMÖ TOMO SCREENING TRIAL Ongoing population based screening trial DBT vs. DM Est 15,000 enrollment, y.o. Est completion June

7 YALE TOMOSYNTHESIS SCREENING TRIAL Retrospective screening trial Compared 2D mammo to 2D + 3D 13,158 women, 6100 had tomo Haas, et al. Comparison of Tomosynthesis Plus Digital Mammography Alone for Breast Cancer Screening. Radiology Dec;269(3): YALE TOMOSYNTHESIS SCREENING TRIAL Recall rate: 30% Cancer detection: 9.6% (P=0.7) 5.7 (3D+2D) vs. 5.2 (2D) Haas, et al. Comparison of Tomosynthesis Plus Digital Mammography Alone for Breast Cancer Screening. Radiology Dec;269(3): CANCER DETECTION Oslo: 27% (P=0.001) Yale: 9.6% (P=0.7) 7

8 RECALL RATES Oslo (FP rate): 5.3% (3D+2D) vs. 6.1% (2D); 15% Yale (2013): 8.4% (3D+2D) vs. 12% (2D); 30% Early studies showed 30% (Gur 2009) and 40% (Poplack 2007) reductions, but with enriched data sets, not screening population ACRIN 4006: Comparison of FFDM with DBT in Screening Call Back Rate 558 enrolled INTERPRETATION TIME Addition of DBT increases interpretation time Avg 1.5 2x for 3D+2D vs. 2D Decrease in total and addl reading time w/ experience. DIAGNOSTIC USE DBT can replace conventional diagnostic mammo views for workup of non calcified lesions recalled from screening Zuley (2013): DBT improved diagnostic accuracy Brandt (2013)/Tagliafico (2012)/Noroozian (2012): DBT comparable to add views 8

9 DIAGNOSTIC USE More accurate determination of lesion size (staging) Mun (2012)/Tingberg (2011) DIGITAL MAMMO VS. TOMO DMIST (2005) performance of DM equivalent to film screen (slightly superior in young women and dense breasts) OSLO (2013) DBT significantly superior to 2D DM for cancer detection and decreased false positives. All densities, especially dense breasts. WHAT S UP AND COMING? Oslo and Malmö screening study results ACRIN 4006 Screening call back study DBT vs. US/AWBUS Contrast enhanced DBT Breast CT vs. 2D and 3D mammo 9

10 CONCLUSION DBT a major step forward in early detection of breast cancer and improvement in false positive rates for screening! DBT is the future of Mammography The Future is Now! THANK YOU! 10