SBI/ACR Breast Imaging Symposium April 7-10, 2016 Austin, TX

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1 SBI/ACR Breast Imaging Symposium April 7-10, 2016 Austin, TX SAM Session 2 Friday, April SAM Credits Thank you for completing this SAM activity. Below you will find correct responses, rationales, and references for the SAM questions. Collective results of the SAM activities will be posted online within 4 weeks following the Symposium so that you can compare your responses to those of your peers. Attendees will receive an when the SAM results are available. When you complete the online CME claim form for the Symposium you must indicate that you completed this activity in order to receive SAM credit for this session. Your SAM certificate will be available in your SBI Education Portal after claiming CME credit for the Symposium. Instructions on claiming CME will be sent by to all attendees after the Symposium concludes. 1. Approximately what percent of newly diagnosed breast cancer patients will be found to have additional cancers on preoperative MRI? a. 0-5% b % c % d % ANSWER: B RATIONALE: Additional cancers are found in 13 to 34% of cases, so B is the most correct response. Plana et al. Eur Radiol 2012; 22: Seely, et al. Eur Radiol 2015; DOI /s published online November. 2. MRI has consistently been shown to lower re-excision rates without increasing mastectomy in which invasive tumor type? a. Squamous b. Apocrine c. Lobular d. Medullary

2 RATIONALE: Invasive lobular has been shown in multiple studies and over time to help significantly decrease re-excision rates without increasing mastectomy rates. Even with ductal cancers, where re-excision rates can be less, mastectomy rates often increase. Fortune-Greeley, et al. Breast Cancer Res Treat 2014; 143: Mann, et al. Breast Cancer Res Treat 2010; 119: Which is true regarding preoperative localization with radioactive seeds, compared to wire localization? a. Seed localization is faster b. Fewer images are needed with seed localization c. Seeds localization costs less d. Surgical approach is more versatile with seeds ANSWER: D RATIONALE: Seed and wire localization are both fast and require about the same number of images. Seeds cost more. However, the surgeon has more opportunity to vary the incision site with seeds than with wires. Alderliesten et al. Breast J 2011; 17(6): year-old with a 2.2 cm unicentric ER/PR negative HER2-amplified carcinoma with normal axillary ultrasound receives appropriate anti-her2 directed preoperative systemic therapy. Following therapy mammogram and ultrasound demonstrate only a 3 mm architectural distortion without suspicious microcalcifications and the prior placed clip. What is the approximate likelihood that she will have a pathologic complete response in the primary tumor and sentinel lymph node? a. 5% in the breast and lymph nodes b. 25% in the breast and lymph nodes c. 50+% in the breast and 90+% in the lymph nodes d. There is no good available data to answer this question RATIONALE: There are extensive published reports on the conversion rate from biopsy proved lymph node-positive disease to pathologic negative lymph nodes and the effect on the breast primary tumor at the time of surgery after preoperative systemic therapy. For cases that receive anti-her2 directed chemotherapy the chance of a complete pathologic response in the breast is in the 40 to 60% range and up to 90% in the lymph nodes.

3 van la Parra RF, Kuerer HM. Selective elimination of breast cancer surgery in exceptional responders: Historical perspective and current trials. Breast Cancer Research, In Press, De Los Santos JF, Cantor A, Amos KD, et al: Magnetic resonance imaging as a predictor of pathologic response in patients treated with neoadjuvant systemic treatment for operable breast cancer. Translational Breast Cancer Research Consortium trial 017. Cancer 2013, 119(10): Heil J, Kümmel S, Schaefgen B, et al: Diagnosis of pathological complete response to neoadjuvant chemotherapy in breast cancer by minimal invasive biopsy techniques. Br J Cancer Dec 1;113(11): Trials are beginning in Europe to evaluate the potential safety of biopsy alone without surgery or radiotherapy for cases of DCIS. One such trial in the United Kingdom is called the LORIS trial. Which of the following are parameters of the LORIS trial? a. It is a single arm phase 2 study b. It is a randomized trial of standard surgery versus active monitoring for patients with less than 1 cm DCIS c. It is a randomized trial of standard surgery versus active monitoring for patients with any size low/intermediate grade DCIS d. There is no such trial (eliminating surgery for DCIS would be impossible and dangerous) RATIONALE: Trials have begun in Europe testing observation of biopsy proved low and intermediate grade DCIS one such trial called the LORIS study is a randomized trial of standard surgery versus active monitoring for patients with any size low/intermediate grade DCIS. The protocol has yearly follow-up mammography with the protocol requirement of biopsy if any lesion develops outside of the initial area of biopsy. If carcinomas identified the patients in the surveillance arm receive standard surgery with and without radiotherapy/endocrine therapy. Kuerer HM. Ductal carcinoma in situ: treatment or active surveillance? Expert Rev Anticancer Ther 15(7):777-85, Francis A, Fallowfield L, Rea D. The LORIS trial: addressing overtreatment of ductal carcinoma in situ. Clin Oncol (R Coll Radiol) 2015;27:6-8. Elshof LE, Tryfonidis K, Slaets L, van Leeuwen-Stok AE, Skinner VP, Dif N, Pijnappel RM, Bijker N, Rutgers EJ, Wesseling J. Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study. Eur J Cancer Aug;51(12):

4 6. 61-year-old presents with a 4 cm triple negative breast cancer with an initial ultrasound that demonstrates two abnormal axillary lymph nodes one of which was biopsied and a clip was placed. The patient receives preoperative chemotherapy with AC-Taxol and imaging shows the primary cancer has decreased in size to 1.2 cm with completely normalized fatty replaced lymph nodes. Potential appropriate safe and accurate nodal surgery would include which of the following? a. Sentinel lymph node biopsy alone without demonstration of the clip removal in the patient b. Sentinel lymph node biopsy with targeted axillary dissection to demonstrate clip removal, and no evidence of metastases c. Random sampling of a few axillary lymph nodes d. Axillary lymph node dissection in all cases regardless of the presence of metastases or not ANSWER: B Caudle AS, Kuerer HM. Targeting and limiting surgery for patients with node-positive breast cancer. BMC Med Jun 25;13:149. Boughey JC, Suman VJ, Mittendorf EA, et al: Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA 310(14): , Caudle AS, Yang WT, Mittendorf EA, Black DM, Hwang R, Hobbs B, Hunt KK, Krishnamurthy S, Kuerer HM. Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg Feb;150(2): Caudle AS, Yang WT, Krishnamurthy S et al: Improved Axillary Evaluation Following Neoadjuvant Therapy for Node Positive Breast Cancer Patients using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection, In Press, J Clin Oncol, Straver M, Loo C, Alderliesten T, Rutgers E, Vrancken Peeters M. Marking the axilla with radioactive iodine seeds (MARI procedure) may reduce the need for axillary dissection after neoadjuvant chemotherapy for breast cancer. Br J Surgery 2010; 97: Plecha D, Bai S, Patterson H, Thompson C, Shenk R. Improving the Accuracy of Axillary Lymph Node Surgery in Breast Cancer with Ultrasound-Guided Wire Localization of Biopsy Proven Metastatic Lymph Nodes. Ann Surg Oncol Dec;22(13): FES-PET is demonstrating the ability to delineate the effectiveness of which of the following therapeutic treatments?

5 a. Her2 targeted therapies b. Alkylating agents c. Estrogen targeting therapies d. Androgen targeting therapies RATIONALE: FES is radiolabeled estradiol that directly targets the estrogen receptor. It has been shown to be useful in monitoring Fulvestrant effects in breast cancer. Measuring residual estrogen receptor availability during fulvestrant therapy in patients with metastatic breast cancer. van Kruchten M, de Vries EG, Glaudemans AW, van Lanschot MC, van Faassen M, Kema IP, et al. Cancer Discovery 2015;5: Why do tumors demonstrate increased uptake of F-18 FACBC? a. Increased lipid metabolism b. Hypoxia c. Proliferation d. Angiogenesis ANSWER: A RATIONALE: FACBC ( 18 F-Fluciclovine) is a leucine analog PET/CT radiotracer that depicts amino acid transport into cells. Amino acid transport proteins have been shown to be upregulated in breast malignancies by microarray and immunohistochemical analysis. Ulaner GA et al., Initial results of a prospective clinical trial of 18 F-Fluciclovine PET/CT in newly diagnosed invasive ductal and invasive lobular breast cancers. Journal of Nuclear Medicine, in press, Which imaging modality has shown the potential to identify HER2 positive metastasis when the primary tumor is HER2 negative? a. FACBC-PET b. Magnavist (Gd-DTPA) c. FDG-PET d. 89 Zr-trastuzumab-PET ANSWER: D RATIONALE: In a proof-of-concept study, it was demonstrated that 89 Zr-trastuzumab-PET/CT detected unsuspected HER2-positive metastases in patients with HER2-negative primary breast cancer.

6 Ulaner GA et al., Detection of HER2-positive metastases in patients with HER2-negative primary breast cancer using 89 Zr-DFO-trastuzumab PET/CT, Journal of Nuclear Medicine, in press, 2016.