1. Breast Imaging
Ravi Adhikary, MD

2. ACS Estimated Cancers Statistics 2014
New Cases in Women
Deaths in Women
Breast
232,670 (+67,570 in situ)
40,000
Colon
48,380
24,040
Cervical
12,360
4,020
Lung
108,210
72,330
Pancreas
22,840
19,420

3. Screening Mammography
Women of average breast cancer risk
Annually starting at age 40
Women with an increased risk
BRCA1/2 mutations, or untested with first degree relatives with BRCA
Yearly, starting by age 30, not before 25
>20% lifetime risk of breast cancer by family history, women with mothers and sisters with premenopausal breast cancer
Starting by age age 30, or 10 years earlier than the diagnosis of the youngest affected relative, but not before age 25
History of mantle radiation (for Hodgkin’s disease)
Yearly starting 8 years after radiation therapy, not before 25
Women with lobular neoplasia, ADH, DCIS, invasive cancer or ovarian cancer
Yearly from time of diagnosis

4. Screening Mammogram Trial Age Follow-up years Mortality Reduction
Health Insurance Plan of Greater NY ( )
40-64 18
23%
Malmo Mammographic Screening ( )
45-69
18-24
19%
Swedish Two County Trial ( )
40-74 20
32%
Edinburgh Trial ( )
45-64 14
29%
Canadian National Breast Screening Study ( )
50-59 13
-2%
Stockholm trial ( ) 8
20%
Gothenburg Breast Screening Trial ( )
40-59
UK Age Trial ( )
39-41 10
17%

5. Mammogram Masses Calcifications Architectural distortion Asymmetries
Other features

6. Breast Density A: Almost entirely fatty
B: Scattered areas of fibroglandular density
C: Heterogenously Dense
D: Extremely dense

8. Potential Problems With Dense Breast Tissue
Increased Relative Risk
Category D vs A: 4 to 6
Category C vs average: < 1.2
Category D vs average: <2.1
Decreased sensitivity of mammography
Category D vs A: Sensitivity decreased 26%
Category C vs average: Sensitivity decreased 7%
Category D vs average: Sensitivity decreased 13%

9. Breast Density Legislation
Women with dense or heterogeneously dense breast tissue receive a letter
New York State has passed legislation and letters have been going out since 2013

10. New York State Law
Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer.
This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.

11. Possible Approaches No further screening
Additional screening with ultrasound and MRI
Benefits may be found in those women who have other risk factors beyond just density

12. Ultrasound Screening
In 6 studies conducted between between evaluating ultrasound screening:
Involving 40,544 women
Cancer detection ranged from /1000 screened, overall 3.4/1000
Mean size of cancer ranged from mm
83%-100% of cancers found to be invasive
86%-100% of cancers found to be node negative

13. Ultrasound Screening Cancers found in screeners: Low risk 1.6/1000
Intermediate Risk
6.7/1000
High risk
11.5/1000

14. Ultrasound Screening Pros Does not require ionizing radiation
No intravenous contrast required
Well tolerated by patient
Availability
Relatively inexpensive
Cons
Does depend on operator
High rate of BI-RADS 3 lesions
Positive predictive value of biopsies is low
Yield of cancer in those women of low risk other than breast density is relatively low

15. Breast Ultrasound
Masses
Calcifications
Other findings

16. MRI Screening Not just for dense breasts High risk groups
Generally starting by age 30
10 years before
>20-25% lifetime risk of breast cancer
BRCA carriers, 1st degree relative of BRCA carrier
Chest radiation (for Hodgkin’s disease)

17. MRI Screening EVA Trial Multicenter study
Evaluate contribution of MG, US, MRI
687 women with >20% lifetime risk
Cancer yield
MG: 5.4
US: 6.0
MG + US: 7.7
MRI: 14.9
MG + MRI: 16.0
MG + MRI + US: 16.0

18. MRI Screening
Those with claustrophobia may not be able to tolerate the exam
Pacemaker
Renal function
Contrast allergy
Limited availability
Expensive

19. Breast MRI
Mass
Non mass enhancement
Focus
Other findings

20. BI-RADS Assessment Assessment Management Likelihood of Cancer
Category 0: Incomplete
Recall for additional imaging and/or comparison with priors
N/A
Category 1: Negative
Routine Screening
Essentially 0%
Category 2: Benign
Category 3: Probably benign
Short interval follow-up
>2%
Category 4: Suspicious
Tissue diagnosis
4C: 50-49%
Category 5: Highly suggestive of malignancy
Tissue Diagnosis
>95%
Category 6: Known biopsy-proven malignancy
Surgical excision when appropriate