Elizabeth Pietras, M'D'

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Elizabeth Pietras, M.D. Director of Breast
Imaging Southern Radiology Division
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A Sharper Image The Latest in Breast Cancer
Screening and Staging

• Elizabeth Pietras, MD
• Director of Breast Imaging
• Spectrum Medical Group
• Southern Radiology Division

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Imaging the High Risk Patient

• Personal history of breast cancer
• Family history of breast cancer or breast cancer
  gene
• Biopsy history- ADH, LCIS
• Limited mammogram
• Breast augmentation

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Introduction

• Breast cancer is 2nd most common malignancy in
  American females
• Search to decrease mortality
• Early detection
• Staging of disease

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Current Modalities

• Mammography-digital mammography
• Breast Ultrasound (US)
• Magnetic Resonance Imaging (MRI)
• Nuclear Medicine-sestamibi, sentinel node and
  positron emission tomography (PET)
• Indications, techniques, examples, limitations

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Mammography

• Accepted as screening and diagnostic tool
• Accessible, easy to perform
• Affordable
• 40 years old and up
• Sensitivity 78-96
• Specificity 87-?
• PPV 15-30

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Digital Mammography

• Requires radiation
• Digital image replacing film
• FDA approved
• GE, Fischer, LoRad
• Efficiency- quick acquisition, no lost films,
  image transfer, new tools, procedures

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Digital Mammography

• Limitations
• 750,000 price tag
• Image storage
• Monitors
• Size of patient
• False positives

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Breast Ultrasound

• Diagnostic tool- beyond cyst versus solid
• Role in screening patients
• Advantages- patient tolerance, no radiation,
  affordable, availability
• Procedures- biopsy and needle localizations

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Breast Ultrasound

• Technique
• High frequency linear array transducer
• Correlation with mammogram and physical exam
• Needle biopsies- favor core biopsy
• Biopsy marking devices
• Needle localizations- skin marking

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Breast Ultrasound

• Limitations
• Operator dependent
• Imaging large or fatty breasts
• Sonographer shortage
• False Positives
• False Negatives- DCIS, microcalcifications

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Magnetic Resonance Imaging (MRI)

• FDA approved for breast imaging
• Indications
• Preoperative planning- negative or limited
  mammogram
• High Risk Patient- BRCA genes
• Positive axillary node with negative mammogram
• Breast augmentation

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Breast MRI

• Indications
• Follow response to treatment
• Recurrence or evaluate scar site
• High risk lesions
• Lobular disease
• Difficult mammogram

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Breast MRI

• Technique
• Neovascularity of tumors
• Prone position
• Fat suppression
• Contrast- gadolinium
• Time
• Computer manipulations
• View on workstation

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Breast MRI

• Advantages
• Anatomic detail
• Multiple planes of imaging
• Chest wall
• Image both breasts
• Sensitivity 94-99

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Breast MRI

• Limitations
• Expense- 1000
• Availability
• Biopsy capability
• Patient limitations- prone, metal, anxiety
• False positives- benign nodules, tissue
• Specificity ?
• DICS, lobular disease

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Nuclear Medicine

• Sestamibi
• 99mTC- myocardial perfusion agent
• Miraluma
• Scintimammography
• Uses similar to MRI

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Scintimammography

• Technique
• Injection of 99mTc sestamibi
• Prone on table with hole for imaging
• Gamma camera
• Images- lateral view and frontal view
• Image both breasts

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Scintimammography

• Advantages
• Well tolerated
• Image both breasts
• Affordable- 200

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Scintimammography

• Limitations
• Limited resolution
• Sensitivity 87 for lesions greater than 1cm, may
  drop to 40 for smaller lesions
• Specificity ?
• Lobular disease, DCIS
• Biopsy capabilities

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Lymphoscintigraphy

• Axillary node status key prognostic indicator in
  breast cancer
• Formal axillary clearance associated with
  significant morbidity
• Improve ways of accurately sampling axilla with
  limited dissection

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Lymphoscintigraphy

• Alternative strategy using intraoperative
  lymphatic mapping by identifying 1st draining
  node or sentinel node
• Melanoma staging
• Limitations of PE, US, CT, MRI
• Spread of malignant tumors to specific nodes that
  lie in direct lymphatic drainage pathway from the
  tumor

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Lymphoscintigraphy

• Technique
• Injection of 99mTc sulfur colloid
• Variability on technique
• Image patient after injection
• Decrease time in OR
• Temporal sequence of draining nodes
• Injection of blue dye
• Intraoperative localization- probe

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Lymphoscintigraphy

• Advantages
• Technique has shown to be useful
• Decrease time in OR
• Increased sections through the node and detection
  of micro metastases
• Predictive value of sentinel nodes 92

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Lymphoscintigraphy

• Disadvantages
• Training and operator dependence
• Expense and availability
• Variability of techniques

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Positron Emission Tomography (PET)

• Functional imaging of tumors
• Nuclear medicine imaging
• 18F-FDG
• Detects metabolic alterations occurring in tumor
  cells- increased glucose metabolism
• FDA approved for cancer imaging

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PET

• Indications
• Approved by Center for Medicare and Medicaid
  Services
• Adjunctive role
• Staging for distant metastases
• Restaging patients, recurrence
• Evaluating tumor response
• Available in Maine

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PET

• Technique
• Fasting state
• Injection of 18F-FDG
• Emission scan
• Scan time 1 hour
• Reconstruct images
• CT correlation

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PET

• Advantages
• Ability to evaluate a large portion of the body
  in one test
• Help characterize lesions found incidentally on
  other imaging tests- US, CT, MRI
• Helpful in evaluating lymph nodes
• Evaluation of scar tissue
• Monitoring response to therapy

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PET

• Limitations
• Cost- 2000
• Availability
• Limitations of evaluating breast itself and for
  screening- detectors
• False positives
• False negatives
• Limited studies

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Conclusions and Questions

• Overview of current options for patients
• Consult your radiologists
• Questions
• Elizabeth Pietras M.D.
• Department of Radiology
• Maine Medical Center