X-Ray Associates of New Mexico, P.C. TOMOSYNTHESIS: WORTH ALL THE HYPE? MICHAEL N. LINVER, MD, FACR
MAMMOGRAPHY: THE GOOD, THE PRETTY GOOD, & THE NOT SO GOOD
MAMMOGRAPHY: THE GOOD, THE PRETTY GOOD, & THE NOT SO GOOD Prompt annual mammography has shown the ability to reduce the mortality rate from breast cancer in a populafon by 15% to 50%. As many as 20% of breast cancers will be missed by 2D mammography. Approximately 10% of women are recalled for addifonal workup and a significant porfon prove to have no abnormality, resulfng in unnecessary anxiety and cost.
MAMMOGRAPHY Gur et al. Trends in Recall, Biopsy, and Positive Biopsy Rates for Screening Mammography Radiology, May 2005; 235: 396-401.
NEW TOOLS IN MAMMOGRAPHY Full Field Digital Mammography ( 2-D ) Tomosynthesis ( 3-D Mammography ) NOW WE CAN SLICE AND DICE!
In 2D DIGITAL MAMMOGRAPHY: Tissue superimposifon hides cancers in 2D Tissue superimposifon mimics cancers in 2D Lesion Superimposed in 2D
THE SOLUTION IS TOMOSYNTHESIS Tomosynthesis is a three-dimensional mammographic examinafon that can minimize the effects of structure overlap within the breast
HOW DOES 3D MAMMOGRAPHY (BREAST TOMOSYNTHESIS) WORK?
3D PRINCIPLE OF OPERATION X-ray tube moves in an arc across the breast A series of low dose images are acquired from different angles Total dose approximately the same as one 2D mammogram ProjecFon images are reconstructed into 1 mm slices Compression { Reconstructed Slices Arc of motion of x-ray tube, showing individual exposures Paddle Compressed Breast Detector Housing
Why Digital Breast Tomosynthesis? 3D improves visibility by reducing tissue superimposition
BREAST TOMOSYNTHESIS (HOLOGIC SYSTEM) LCC 2D
LCC 2D
3D 2D 2D
BREAST TOMOSYNTHESIS (HOLOGIC SYSTEM) ANOTHER CASE: 3D 2D
BREAST TOMOSYNTHESIS (HOLOGIC SYSTEM) 3D 2D
3D 2D
The Value of 2D Plus Breast Tomosynthesis Breast cancer screening with tomosynthesis finds more cancers than convenfonal 2D mammography 1 Tomosynthesis gives radiologists the confidence to significantly reduce recall rates 2 Masses, distorfons and asymmetric densifes are beder visualized with breast tomosynthesis 3 1. Skaane P, Gullien R, Eben EB, et. al. Reading Fme of FFDM and tomosynthesis in a populafon-based screening program. Radiological Society of North America annual meefng. Chicago, Il, 2011. 2. FDA PMA submission P080003 3. Bernardi D, Ciado S, Pellegrini M, et. al. ProspecFve study of breast tomosynthesis as a triage to assessment in screening. Breast Cancer Res Treat. 2012 Jan 22 [Epub ahead of print]. AND RECENT STUDIES:
2-D CONVENTIONAL DIGITAL MAMMOGRAPHY vs 2-D PLUS 3-D TOMOSYNTHESIS 12,631 Screening Studies 2-D Digital Mammo alone: 6.1/1000 detect. rate 2-D + 3-D Tomosynthesis: 8.1/1000 detect. rate Difference: 25% increase in cancer detection rate with tomosynthesis (25 more cancers) False Positive rate: Decreased by 15% (61/1000 vs. 53/1000) with tomosynthesis Skaane P, Bandos AI, Guillien R, et al. Comparison of digital mammography alone with digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013, vol. 267: pp. 47-56.
2-D CONVENTIONAL DIGITAL MAMMOGRAPHY vs 2-D PLUS 3-D TOMOSYNTHESIS
PERFORMANCE OF DIGITAL MAMMOGRAPHY & DBT OVER TIME McDonald ES, Oustimov A, Weinstein SP. Effectiveness of DBT compared to Digital Mammography: Outcomes analysis from 3 years of breast cancer screening. JAMA oncol. published online 2/18/2016; doi:10.1001/jamaoncol.2015.5536
THEREFORE, CURRENT STUDIES SHOW THAT TOMOSYNTHESIS IN THE SCREENING SETTING TRULY CAN FIND MORE CANCERS, AND DECREASE THE RECALL RATE, AT THE SAME TIME! WHO SAYS THERE IS NO FREE LUNCH?
TOMOSYNTHESIS: WHERE IS IT MOST HELPFUL? Greatest application: architectural distortion Also good for masses Does it have any value added for calcifications? So far, the reviews are mixed
TOMOSYNTHESIS: ITS ROLE IN THE INTERPRETATION OF CALCIFICATIONS Tomosynthesis does NOT have an important role in the DIAGNOSTIC evaluation of calcifications seen at screening Intrinsic resolution not as good as 2D Tomosynthesis does have some value vis-avis calcifications as part of the screening mammogram It has certain advantages over 2D, and certain disadvantages as well
ADVANTAGES OF TOMOSYNTHESIS FOR EVALUATION OF CALCIFICATIONS Eliminates superimposed tissue: potentially see calcifications in that plane better Good for dense breast tissue Find precise locations of calcifications in space Excellent for skin calcifications Allows better visualization of surrounding tissues Great for identifying an associated mass in dense breast tissue
ADVANTAGES OF TOMOSYNTHESIS FOR EVALUATION OF CALCIFICATIONS Eliminates superimposed tissue: potentially see calcifications in that plane better Good for dense breast tissue Find precise locations of calcifications in space Excellent for skin calcifications Allows better visualization of surrounding tissues Great for identifying an associated mass in dense breast tissue
? VASCULAR CALCS! 2D TOMO SLICE
ADVANTAGES OF TOMOSYNTHESIS FOR EVALUATION OF CALCIFICATIONS Eliminates superimposed tissue: potentially see calcifications in that plane better Good for dense breast tissue Find precise locations of calcifications in space Excellent for skin calcifications Allows better visualization of surrounding tissues Great for identifying an associated mass in dense breast tissue
SCREENING MAMMOGRAM?
SCREENING MAMMOGRAM?
SKIN CALCS! (POWDER TRAPPED IN SKIN PORES) TOMO SLICE #1
WHAT ABOUT TOMOSYNTHESIS IN THE DIAGNOSTIC SETTING?
TOMOSYNTHESIS IN THE DIAGNOSTIC SETTING Screening Tomo is a DIAGNOSTIC tool, with better lesion characterization & improved lesion visibility, resulting in less screen recalls Screening Tomo is often as good or better than diagnostic 2D spot mammogram views Must perform both CC & MLO screening Tomo views to optimize cancer detection & analysis
CURRENT LEFT CC (2D) CURRENT LEFT MLO (2D)
CURRENT LEFT CC (3D) CURRENT LEFT MLO (3D)
NO ADDITIONAL SPOT VIEWS NECESSARY! CURRENT LEFT MLO (3D) CURRENT LEFT MLO (2D) INVASIVE DUCTAL CARCINOMA
TOMOSYNTHESIS IN THE DIAGNOSTIC SETTING Screening Tomo is a DIAGNOSTIC tool, with better lesion characterization & improved lesion visibility, resulting in less screen recalls Screening Tomo is often as good or better than diagnostic 2D spot mammogram views Must perform both CC & MLO screening Tomo views to optimize cancer detection & analysis Additional spot Tomo views are also useful, especially for evaluation of anterior lesions Suspicious calcifications should always be evaluated with 2D spot magnification views
TOMO CC SLICE 2D CC IMAGE CC SPOT 2D VIEW
WHAT ABOUT DOSE?
WHAT ABOUT DOSE? Comparison of Doses: Standard 4-view Screening Exam Hologic System 2D Plus 3D Tomosynthesis New Mexico
SYNTHESIZED 2D VIEW NOW HERE: C-VIEW (HOLOGIC) Synthesized 2D Real 2D Courtesy Steven Poplack, MD
C-view Synthesized 2D Image How does it work? Perform a standard tomosynthesis scan (exisfng system) Reconstruct tomosynthesis slices (exisfng system) Synthesize 2D image (C-View) Similar to Maximum Intensity ProjecFon (MIP) as done with MRI images ~60 Tomosynthesis Slices Image Summation C-View
Arch. DistorFon only on s2d and DBT 51 yo architectural distorfon seen only on s2d/dbt Pathology: invasive ductal carcinoma. DM DBT s2d
SyntheFc 2D with Tomosynthesis DM s2d Pathology: Ductal Carcinoma in situ (DCIS)
RADIATION DOSE WHEN SYNTHETIC VIEW IS ADDED TO TOMOSYNTHESIS VIEW: NO ADDED RADIATION DOSE! Comparison of Doses: Standard 4-view Screening Exam C-view plus Tomo Hologic System 2D Plus 3D Tomosynthesis New Mexico
A FEW REPRESENTATIVE CASES:
Case 1 IMPROVED SENSITIVITY: MASSES
2D 3D
Digital Mammo (2D) Tomo Slice (3D) INVASIVE DUCTAL CARCINOMA
Case 2 IMPROVED SENSITIVITY: MASSES
Hx: 46 year old, previous lumpectomy on Lel for cancer IndicaFon: Annual Screening Comparison studies: None available
CC view
MLO view
CC LEFT
POST-OPERATIVE SCAR MLO LEFT
CC RIGHT
CC RIGHT
CC RIGHT
MLO RIGHT
MLO RIGHT
MLO RIGHT
INVASIVE DUCTAL CARCINOMA
Case 3 IMPROVED SENSITIVITY: ARCHITECTURAL DISTORTION
2D RCC 70
2D RCC 71
2D Tomo Slice (3D) INVASIVE LOBULAR CARCINOMA 72
Another case: REDUCTION OF RECALLS: PSEUDO-LESIONS
2D LMLO
2D LMLO
LMLO LLM LSMLO 2D DiagnosFc Images 76
Digital Mammo (2D) Tomo Slices (3D) NO MASS SEEN: Superimposed Blood Vessel! 77
NOW WE CAN SAVE LIVES LIKE NEVER BEFORE, AND - WE CAN CALL LESS PATIENTS BACK TO DO SO! (A REAL WIN-WIN SITUATION!)
FOR QUESTIONS OR CONCERNS, PLEASE CONTACT ME AT: MAMMOMIKE@AOL.COM
Thank you!