Emerging Technologies in Breast Imaging
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1 June 30, 2016 Emerging Technologies in Breast Imaging Jay A. Baker, M.D. Division of Breast Imaging
2 New Technologies in Breast Imaging Full Field Digital Mammography (FFDM) X-ray/Mammography Computer-Aided Detection (CAD) Contrast Enhanced Spectral Mammography Ultrasound Digital Breast Tomosynthesis (DBT) Contrast Enhanced Tomosynthesis MRI Dedicated Breast CT Tissue Harmonic Imaging (THI) Nuclear Medicine Compound Imaging Elastography Extended Field of View Imaging (EFOV) Other Automated Breast Ultrasound (ABUS) Diffusion Weighted Imaging (DWI) Diffusion Tensor Imaging Gamma Imaging (BSGI/MBI) Positron Emission Mammography (PEM) Radioactive Seed Localization Optical Imaging
3 New Technologies in Breast Imaging Full Field Digital Mammography (FFDM) X-ray/Mammography Computer-Aided Detection (CAD) Contrast Enhanced Spectral Mammography Ultrasound Digital Breast Tomosynthesis (DBT) Contrast Enhanced Tomosynthesis MRI Dedicated Breast CT Tissue Harmonic Imaging (THI) Nuclear Medicine Compound Imaging Elastography Extended Field of View Imaging (EFOV) Other Automated Breast Ultrasound (ABUS) Diffusion Weighted Imaging (DWI) Diffusion Tensor Imaging Gamma Imaging (BSGI/MBI) Positron Emission Mammography (PEM) Radioactive Seed Localization Optical Imaging
4 Lecture Outline Contrast Enhanced Mammography Gamma Imaging courtesy of Dr. Andrew Maidment Radionuclide seed localization
5 Lecture Outline Contrast Enhanced Mammography Gamma Imaging courtesy of Dr. Andrew Maidment Radionuclide seed localization
6 GE Medical Systems, Inc. Contrast Enhanced Digital Mammography CEDM General approach: modified digital mammography system iodinated contrast material
7 Contrast Enhanced Digital Mammography CEDM General approach: modified digital mammography system iodinated contrast material + Iodine Iodine Sub two images subtract one image from another iodine-only image
8 Contrast Enhanced Digital Mammography Modifications Contrast Enhanced Digital Mammography kvp copper filter rapid filter change Temporal Subtraction k-edge of iodine Dual Energy
9 Contrast Enhanced Digital Mammography Contrast Enhanced Digital Mammography Temporal Subtraction Dual Energy
10 Contrast Enhanced Digital Mammography Contrast Enhanced Digital Mammography Temporal Subtraction Dual Energy
11 Temporal Subtraction Before & After inject contrast position patient and light compress baseline image (mask) at kvp inject iodine contrast ml/sec repeat images q1 minute over 3-5 min subtract mask from subsequent images all images high energy: kvp
12 Temporal Subtraction post pre-con subtract (mask)
13 Jong RA, Yaffe M, et al. Radiology 2003
14 Temporal Subtraction Advantages high energy = low dose kinetic curves (MRI) low cost vs MRI Disadvantages long exam time motion misregistration one projection only (can t move) kinetics not robust compressed breast longer time to inject miss sec window
15 Jong RA, Yaffe M, et al. Radiology 2003
16 Contrast Enhanced Digital Mammography Contrast Enhanced Digital Mammography Temporal Subtraction Dual Energy
17 Contrast Enhanced Digital Mammography Contrast Enhanced Digital Mammography Temporal Subtraction Dual Energy
18 Dual Energy Subtraction CESM = Contrast Enhanced Spectral Mammography dual energy technique both images after contrast one sees contrast; other doesn t
19 Dual Energy Subtraction x-ray absorption of iodine at dif energies high absorption at high energy (45-49 kvp) low absorption at low energy (26-32 kvp) k-edge of iodine
20 Dual Energy Subtraction x-ray absorption of iodine at dif energies high absorption at high energy low absorption at low energy inject 1.5 ml/kg 3cc/sec wait 2 min position & compress in MLO; hi/lo E images hi/lo E images in all 4 projections (5 min)
21 Dual Energy Subtraction Advantages Disadvantages no motion issues shorter compresion multiple projections
22 Case 1 79 yo w palpable mass, left breast standard mammogram GE Healthcare, Inc images courtesy of Mikawa Breast Center, Mikawa,
23 Invasive Ductal Carcinoma 2min Low Energy Subtraction 4min Subtraction Low Energy GE Healthcare, Inc images courtesy of Mikawa Breast Center, Mikawa,
24 Case 2 Invasive Ductal Carcinoma 2min Low Energy Subtraction 4min Subtraction Low Energy GE Healthcare, Inc images courtesy of Mikawa Breast Center, Mikawa,
25 Case 3 Invasive Lobular Carcinoma 2min Low Energy Subtraction 4min Subtraction Low Energy GE Healthcare, Inc images courtesy of Mikawa Breast Center, Mikawa,
26 Dual Energy Subtraction Advantages no motion issues shorter compresion multiple projections Disadvantages dose
27 Contrast Enhanced Digital Mammography Dose dual energy 1.2x routine mammo high energy = 0.2x mmg low energy = 1.0 mmg 4 views 4.8x mmg temporal subtraction 0.2x mmg pre post images total 1.0 mmg
28 CEDM Clinical Studies Thibault Eur Radiol 2011 Methods prototype dual energy (spectral) n=142 lesions (80 malignant) compare: mammo alone mammo + US mammo + CESM
29 CEDM Clinical Studies Thibault Eur Radiol 2011 Methods prototype dual energy (spectral) n=142 lesions (80 malignant) Sensitivity Specificity ROC multifocal lesions detected mammo mammo + US mammo + CEDM 0.93 * 0.56 * 0.88 * 23
30 CEDM Clinical Studies Jochelson MS (MSK) Radiology 2013 Methods prototype dual energy (spectral) n=52 women; bx-proven malignancy MRI vs dual energy CESM
31 CEDM Clinical Studies Jochelson MS (MSK) Radiology 2013 Methods prototype dual energy (spectral) n=52 women; bx-proven malignancy mammo MRI CESM Index lesion (n=52) 81% 96% 96% Multifocal/centric (n=25) 28% 88% 56% Contralateral CA (n=1) False positives 13 2
32 Pros/Cons CEDM Advantages cost accessibility false positives Disadvantages contrast reaction contrast nephropathy patient acceptibility lack of image-guided bx
33 CEDM State of the Art imaging system Health Canada and FDA-approved (GE) software upgrade to existing units (2010) generator already capable of kvp copper filter billing HCPCS G0204 bilat digit mammo CPT diagnostic injection contrast material
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36 Lecture Outline Contrast Enhanced Mammography Gamma Imaging Radionuclide seed localization
37 In the beginning Cardiolite Tc-99m sestamibi (20 mci) (2-methoxy isobutyl isonitrile) cardiac perfusion imaging itonline.net itonline.net
38 In the beginning Cardiolite Tc-99m sestamibi (20 mci) (2-methoxy isobutyl isonitrile) cardiac perfusion heart thyroid submandibular glands liver breast cancer S Usmani BJR, 83, 2010
39 Why does sestamibi concentrate in breast cancer?
40 Why does sestamibi concentrate in breast cancer? unclear 90% concentrates in mitochondria depends on regional blood flow angiogenesis tissue metabolism courtesy of Dr. Andrew Maidment
41 Small Field of View Gamma Cameras
42 Dedicated Breast Gamma Cameras Courtesy of GE Healthcare Courtesy of Gamma Medica Courtesy of Dilon Technologies BSGI = Breast Specific Gamma Imaging (analog) MBI = Molecular Breast Imaging (digital, CZT detector)
43 Small FOV Camera high resolution (<2mm) scatter from liver, heart mild compression detector-to-breast narrow dead zone at edge visibility medially visibility posteriorly Courtesy of GE Healthcare same projections as mammo
44 Imaging Technique Tc-99m sestamibi dose = mci <20 mci is off-label wait 5-15 min 10 min per projection (4 total 60min) light compression CC and MLO positions match mammo
45 50 yo High risk screening Courtesy of R. Brem, GWU invasive ductal carcinoma
46 Clinical Trials
47 BSGI Accuracy Brem RF, Radiology 247, 2008 retrospective review of BSGI n =146 women (variety of indications) n =167 lesions (83 malignant) 30 mci Tc-99m-sestamibi (CC and MLO) Results Sensitivity Specificity PPV NPV BSGI 96% 60% 69% 94% BSGI 1cm 85%
48 MBI Screening Rhodes DJ. Radiology 258, 2010 (Mayo) MBI for screening n=936 women hetero or extremely dense tissue
49 MBI Screening Rhodes DJ. Radiology 258, 2010 (Mayo) MBI for screening n=936 women hetero or extremely dense tissue moderate-high risk 20 mci Tc-99m sestamibi Risk Factors BRCA1 or BRCA2 Lifetime risk 20% 5-yr risk % Mantel or axilla radiation Personal hx of breast CA Hx of ADH, ALH, LCIS, etc Family Hx of breast cancer
50 MBI Screening Rhodes DJ. Radiology 258, 2010 (Mayo) MBI for screening n=936 women hetero or extremely dense tissue moderate-high risk 20 mci Tc-99m sestamibi Results Cancers Mammo 1 MBI 7 Both 2 Neither 1 TOTAL 11
51 MBI Screening Rhodes DJ. Radiology 258, 2010 (Mayo) MBI for screening n=936 women hetero or extremely dense tissue moderate-high risk 20 mci Tc-99m sestamibi Results Mammo MBI Both CA/ p=0.016
52 Courtesy of GE Healthcare High risk screening, Normal mammogram Bx = 5mm invasive ductal CA
53 Gamma Imaging Limitations false positives NPV < 98% (ie., cannot rule-out cancer) availability fat necrosis dose FDA = mci req d = 2-4 mci courtesy of R. Brem, GWU
54 Low Dose MBI Screening Rhodes DJ. AJR 204, 2015 (Mayo) MBI for screening n=1585 women hetero or extremely dense tissue improved collimator; wider energy window 8 mci Tc-99m sestamibi Results Mammo MMG/MBI CA/ p<0.001
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56 Lecture Outline Contrast Enhanced Mammography Gamma Imaging Radionuclide seed localization
57 Disclosure Off label usage: Breast localization with an I-125 radioactive seed is off label use of this FDA-approved product.
58 Traditional Wire Localization Wire placed using mammo or ultrasound guidance Wire skewers lesion Surgeon uses wire as roadmap to lesion
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60 Traditional Wire Localization Pros easy placement accurate excision standard-of-care Cons uncomfortable procedure wire in place lengthens day for patient can t be first case for O.R. limits surgical approach wire kinks send surgeon in wrong direction localization must be done in same facility as surgery
61 Radioactive Seed Localization I-125 seed, sealed titanium source prostate brachytherapy seed but lower dose Seed placed using mammo or ultrasound guidance Seed placed within the lesion and/or near biopsy marking clip Surgeon uses handheld gamma probe to detect seed and dissect down to seed
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67 Accuracy McGahn LJ, et al. Ann Surg Onc Oct RSL procedures 97% negative margin on 1 st excision 9% re-excision for close margin
68 Accuracy Lovrics PJ, et al. Ann Surg Onc Nov 2011 >300 cases: half RSL / half wire loc WIRE LOC SEED LOC Positive Margins 11.5% 10.8% Operative Time 22.2 min 19.4 min Surgeon Preference p=0.008 Patient Pain p=0.04 p=ns p<0.001
69 Radioactive Seed Localization Pros easy, comfortable procedure no wire in place done 1-5 days before O.R. shortens day for patient any surgical approach can be first case of day same or better positive margin rate (seed placed at lesion; seeds don t migrate) seed placement disconnected from O.R. location Cons uncomfortable procedure radioactivity bracketing is challenging seed cannot be repositioned billing issues for Radiology losing a seed creates substantial problems
70 Because of it s benign physical properties, Iodine- 125 is not THIS complicated to deal with...
71 Proper Handling of Seeds This Way......NOT This Way!
72 Seed Program Challenges Start up cooperation: Radiology Surgery Pathology Radiation Safety Learning curve Administrative oversight Reimbursement issues
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75 Conclusions Contrast Enhanced Mammography potential alternative to MRI Gamma Imaging (BSGI or MBI) limited utility for work-ups screening requires dose reduction Radioactive Seed Localization advantages for patient, surgeon, radiol requires cooperation and oversight
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77 THANK YOU
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85 Courtesy of GE Medical Systems, Inc. Metabolic
86 now near future
87 CESM Case 3 CESM Image Rt CC 2 min. CESM Image Rt MLO 4 min. Images courtesy of Dr Mizutani Mikawa Breast Cancer Clinic Miakawa-anjo, JAPAN
88 Thibault F. EJR Sept 2012 Fig. 2. Same patient as in Fig. 1. Preoperative bilateral contrast enhanced spectral mammography. Post-contrast lowenergy (a-b) and combined images (c-d). Contrast uptake is highlighted in both index lesion and anterior focus (arrows). No significant enhancement of breast tissue is seen otherwise. Note similar lesion visibility on CESM and
89 History of Breast Imaging 1895 Wilhelm Roentgen discovers the x- ray 1913 Albert Salomon images mastx specimens 1930 Stafford Warren invents mammogram
90 History of Breast Imaging 1895 Wilhelm Roentgen discovers the x-ray 1913 Albert Salomon images mastx specimens 1930 Stafford Warren invents mammogram 1950 s Robert Egan, dedicated mammo film 1966 first dedicated mammo machine 1970s xeromammography 1980s plain film analog mammography 2000 first digital mammography system
91 History of Breast Imaging 1895 Wilhelm Roentgen discovers the x-ray 1913 Albert Salomon images mastx specimens 1930 Stafford Warren invents steroscopic technique for imaging breast in vivo 1950 s Robert Egan, reproducible, low kvp technique 1966 first dedicated mammo machine (CGR Senographe, France) 1971 xeromammography 1972 first dedicated mammo film/screen combination (DuPont) 1980s plain film analog mammography 2000 first digital mammography system (GE) 2011 digital breast tomosynthesis (Hologic)
92 osa.edu
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94 History of Breast Imaging 1895 Wilhelm Roentgen discovers the x-ray 1913 Albert Salomon images mastx specimens 1930 Stafford Warren invents steroscopic technique for imaging breast in vivo 1950 s Robert Egan, reproducible, low kvp technique 1966 first dedicated mammo machine (CGR Senographe, France) 1971 xeromammography 1972 first dedicated mammo film/screen combination (DuPont) 1980s plain film analog mammography 2000 first digital mammography system (GE) 2011 digital breast tomosynthesis (Hologic)
95 What Will It Take? Out-side-the-box concepts and engineering Compelling empiric data Screening vs Diagnostic vs Extent of Disease Consecutive case series Multi-institutional data Convenience (prone, water bath, etc) Cost Reimbursement Biopsy capability (eg., ARIA)
96 FFDM CAD dual energy contrast enhanced CESM tomo contrast tomo tomo CAD
97 asdf Review emerging technologies Discuss potential role in patient care Problem solving? What is NPV? Compare claims to empiric data
98 Tomosynthesis
99 Case 4 Invasive Ductal Carcinoma
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101 F ½ by 1 ½
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108 Contrast Enhanced Digital Mammography Equipment modified mammo gantry generator/tube: kvp fast kv switching: avoid motion (dual sub) copper filter power injector
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110 Disclosure Siemens Medical Systems tomosynthesis grant
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