Breast Imaging: Multidisciplinary Approach Madelene Lewis, MD Assistant Professor Associate Program Director Medical University of South Carolina
No Disclosures
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
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
Multidisciplinary Approach Team of Breast Experts Radiology Pathology Surgery Radiation Oncology Medical Oncology Plastic Surgery Genetic Counselors Nurse Coordinators and Navigators Survivorship
Multidisciplinary Breast Clinic
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
The MUSC Model Wednesday AM: Concordance conference Thursday AM: Multidisciplinary tumor board Thursday following TB: Multidisciplinary clinic
Cases
42 yo female screening mammogram
US Biopsy Invasive Ductal Carcinoma ER+, PR+, HER2-
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-, HER2-10-20% 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
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)
36 yo female with left upper outer quadrant palpable mass
US Biopsies IDC-Triple Negative Metastatic Intramammary Lymph Node
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
Normal
Axilla SLN metastases <0.2mm-isolated tumor cells (ITCs) pn0(i+) 0.2mm-2mm micrometastases N1(mi) >2mm macrometastases N1
Assessing Extent of Disease
47 year old with palpable mass
Nipple Involvement
Muscle Invasion
Abuts no invasion
Metastasis to Latissimus Dorsi
Skin Involvement
Biopsy proven cancer MRI detected contralateral cancer
Osseous Metastatic Disease
56 year old screening mammogram
US Bx-IDC ER-, PR-, HER2+
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
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
Evaluation of the Specimen Radiograph Lesion present? Wire/seed/clip present? Location of lesion within specimen
Specimen Radiograph for Margin Assessment Not reliable for judging adequacy of excision More accurate when it suggests incomplete excision
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
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
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
NAC
NAC
BIRADS?
Monitoring for Recurrence MUSC Imaging Algorithm 6 months after completion of XRT Spot compression view of lumpectomy bed Annual Mammogram
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
Typical Findings with BCT Mass/seroma Architectural distortion Fat necrosis Trabecular edema Skin thickening
Post BCT: Seroma
Post BCT: Architectural Distortion
6 months post XRT 2.5 years post treatment
Post BCT: Calcifications
Post Lumpectomy
Fat Necrosis
Post BCT: Edema, Skin Thickening
Site of Recurrence 2% 2% 23% 10% 63% Same site Same quadrant Remote Radiation Induced Diffuse
Post Lumpectomy
1 year later
Current Prior
Recurrence at Lumpectomy Site
US Bx: Metastatic Lymph Node
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