MAMMOGRAPHY TODAY Kathryn Evers, MD, FACR

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MAMMOGRAPHY TODAYKathryn Evers, MD, FACR
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Diagnostic tools

• Mammography
• Film-screen (analog)
• Digital
• Ultrasound
• MRI
• Nuclear Medicine

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Coming Attractions

• Tomosynthesis
• Contrast Enhancement
• PEM
• Nanoparticles

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Mammography, either film-screen or digital,
remains the mainstay of breast imaging.
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Problems with Mammography

• Patient discomfort (compression)
• Ionizing radiation
• Accuracy
• Difficult to interpret

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How Accurate is Analog Mammography?

• Most recent estimate is 20-30 of cancers may not
  be visible on mammography. (Prior estimates were
  10-20).
• Differences in accuracy between readers.

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Digital Mammography
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Digital Mammography

• Uses radiation to produce an image
• Breast is compressed
• Electronic x-ray detector replaces the films
  cassette
• Photons are converted to light which travels to a
  device which converts this to a digitized signal
  to display on a computer monitor

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Digital Mammography

• Several different systems in use that use
  different types and arrays of detectors
• Images cannot be easily transferred between
  systems from different manufacturers

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Digital mammographyAdvantages

• Higher contrast resolution
• Ability to manipulate image to increase
  visibility
• Fewer repeat exams for poor exposure
• Faster patient throughput
• Eliminates processing issues
• Simplifies storage and retrieval of images
• Possibility of reading at remote sites

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Digital mammographyDisadvantages

• Cost
• May be less accurate in women with fatty breasts

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Digital mammography

• More accurate in women under age 50
• Women with dense breasts
• Premenopausal and perimenopausal women
• DMIST study. Diagnostic Performance of Digital
  versus Film Mammography for Breast-Cancer
  Screening. NEJM, 9/16/05

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Computer Assisted Detection(CAD)

• Digitized images examined by a computer algorithm
  to detect calcifications and masses

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CADAdvantages

• Relatively inexpensive
• Computer does not get distracted or tired (no
  observational oversights)
• Increases accuracy of mammography
• Conventional images can be digitized
• Less expensive than a true double read

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CADDisadvantages

• Inability to compare with earlier studies
• Significant false positive rate
• Unknown false negative rate (not zero)
• Adds to cost of examination (relatively small)
• May decrease accuracy of mammography

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CAD

• New England Journal of Medicine 4/2007
• Increased number of recalls
• Increased biopsy rate
• Decreased accuracy
• Decreased positive predictive value
• Increased biopsy rate did not increase positive
  diagnoses

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Ultrasound
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Screening ultrasound is not recommended by any of
the major organizations (includes ACS, ACR, SBI).
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Ultrasound

• Use in addition to mammography
• Decide if a mass is cyst or solid
• Evaluate palpable mass
• Guide for biopsy

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carcinoma
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MRI
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Breast MRI

• High sensitivity, low specificity
• Expensive
• Requires injection of gadolinium contrast

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Positive fam hx., mammo -, MRI
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Pos. fam. Hx, mammo -, MRI
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SCREENING IN HIGH RISK PATIENTS
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Annual screening MRI recommended (evidence based)

• BRCA mutation
• First-degree of BRCA carrier, untested
• Lifetime risk 20-25 or higher

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Recommend Annual MRI (consensus)

• Radiation to chest between ages 10-30
• Li-Fraumeni syndrome and first-degree relatives
• Cowden and Bannayan-Riley-Ruvalcaba syndromes and
  first-degree relatives

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Insufficient Evidence to recommend for or against
MRI screen

• Lifetime risk 15-20
• LCIS or ALH
• ADH
• Heterogeneously or extremely dense breasts on
  mammography
• Women with a personal history of breast cancer,
  including DCIS

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Recommend against MRI Screening(consensus)

• Women at lt15 lifetime risk

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SCREENING

• In the highest risk women, both screening and MRI
  should be performed yearly
• Due to the high incidence of interval cancers and
  aggressive tumors, there should be an examination
  performed every 6 months, alternating between MRI
  and mammography

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Tomosynthesis
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What is Tomosynthesis?

• 3-D X-ray mammography
• High in-plane resolution (100 microns)
• 1 mm thin slices

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Why Tomosynthesis?

• Reduced radiation (fewer views recalls)
• Fewer compressions
• Potential for reduced compression pressure

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Conventional 2-D Imaging
Incident X-rays
Objects being imaged
Shapes superimposed on image
2-D image
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Tomosynthesis Acquisition
Image from multiple angles
Incident X-rays
Objects being imaged
2-D raw data images
Exposure 1 Exposure 6 Exposure 11
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Tomosynthesis Reconstruction
Appropriate shifting and adding of raw data
reinforces objects at specific height
Height 1
Height 2
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Digital v Tomosynthesis
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Tomosynthesis images
Normal mammogram
Tomosynthesis slices
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CONTRAST ENHANCED DIGITAL MAMMOGRAPHY
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Patient With Benign Lesion (Fibrocystic Change)
Scout
Scout
5 min.
1 min.
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Patient With Malignant Lesion (IDC)
Scout
7 min.
1 min.
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Conclusions

• Mammography remains the basic breast imaging
  examination
• Digital mammography provides better visualization
  in dense breasts
• Tomosynthesis may improve diagnosis
• Screening MRI is recommended yearly for women at
  high risk because of family history