Breast Imaging: Multi-modality case management

Breast Imaging:

Multi-modality case

management

@DrJiyonLee

Jiyon Lee MDClinical Associate Professor

Dept of RadiologyNYU School of Medicine

Jiyon.Lee@nyumc.org

No disclosures

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Breast radiologists as OperatorsOur special considerations/challenges

Technical/operative:-choice of modalities

-lesion location

-visibility

-breast thickness

-contraindications uncommon

-complications uncommon

Radiologic/rad-path:-”false positive”

-false negative—don’t forget!

-did you get the lesion?

-deciding when done

-follow up imaging or excise?

-patient preferences!

-potential loss to follow up (importance of direct communic)

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Case 1 (collection)

• (Images will be shown in ppt)

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Case 2

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Case 2–Q

31 year old white woman (average risk) presents with a new right palpable lump x 1 month. She does do periodic self-breast exam (SBE). Which tests to use and in which order?

A. Nothing needed. Average risk. Likely benign anyway.

B. Breast ultrasound only, because of radiation risk. Maybe biopsy and clip, then do mammo.

C. Straight to palpation guided core biopsy or excision. More efficient.

D. Bilateral diagnostic mammo and ultrasound. Biopsy as indicated by imaging

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Case 2– Answer

She is 31, of average risk, presenting with a new palpable lump. Which tests and in which order?

For over 30, usually start with mammography--balance risk and benefit. Comparison breast is helpful and makes exam complete.

Ultrasound and biopsy as indicated by imaging and clinical details.

But art of medicine, can start with ultrasound too as in this case.

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Case 3

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59yo screening

2D mammographyAlso opted in for 3D.

BMLO and BCC C-views

Had screening ultrasound appointment too.

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LCC. LCCspot.

LMLOspot. LLM.

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Diagnostic ultrasoundLooking for correlate for mammofinding

Is this a match?

What next?

Did we look everywhere else, bilaterally, including axilla?

What next?

If 2D + screening US +dense BT, then which modality gets credit for cancer detection?

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Biopsy?

Which method?

US-core biopsy=IDC involving radial scar…

What next?What if radial scar alone?

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What if she had had screening ultrasound last year?

Have supplemental screening ultrasound data proved mortality benefit?

Will it ever?

And so what?

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Case 3–Q

Spiculated mass on screening mammo. Workup and biopsy showed “invasive ductal carcinoma involving a radial scar.” Is this concordant? What is next management step?

A. BI-RADS 6, concordant. Rec surgical and oncologic management

B. BI-RADS 3, because the IDC is in a radial scar so doesn’t really count. Rec imaging follow up.

C. BI-RADS 4, because the IDC might be a false positive. The RS might be a false positive too. Rec surgery for more info.

D. BI-RADS 2, because IDC might be a false positive. And RS is not cancer. High risk lesions are benign. Rec routine imaging.

E. BI-RADS 0, need more information. Rec surgery.

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Case 3– Answer

Spiculated mass on screening mammo. Workup and biopsy showed “invasive ductal carcinoma involving a radial scar.” Is this concordant and what is next management step?

A. BI-RADS 6, concordant. Rec surgical and oncologic management

Disc: spiculated mass ddx includes malignancy and “false positives” such as radial scar and fat necrosis (that would be benign and concordant). Cancer -> surgery but in many institutions, so might RS because it’s a high risk lesion, and may be associated with cancer at time of detection. The so called “upgrade potential” at surgery.

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Case 4

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Case 4

• Dubai Princess. Visiting the USA. Has a recent palp. Submitted OSF only after the workup with us.

• Nonspecif Mg, US.

• CBU. HRL.

• Exc vs STFU. Use judgment.

• We’re doctors not robots.

• We’re real intelligence, not artificial intelligence.

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Case 432 yo Dubai Princess, with palpable concern, right lower

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Case 432 yo Dubai Princess, with palpable concern, right lower

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Case 432 yo Dubai Princess, with palpable concern, right lower

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• Concordant…and benign…so far…?

• Patient traveling so opts out of excisional biopsy for full histopath…

• Not all HRLs go straight to excision—balance clinical and shared decision making

• Short term follow up imaging (STFU)—only effective if the patient does follow through with the follow up.Make sure she’s informed of results, and aware of the why the f/u

We’re doctors, not robots.Real intelligence, not artificial intelligence

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Case 5

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Case 5: “False positives”

“False positives”-avoidable kind?

unavoidable kind?

“False negatives”- also avoidable kind?

Sensitivity= TP/(TP+FN)

Specificity= TN/(TN+FP)

Do what you can about what/where you can to optimize the process

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Case 5 -- sidestepping the FPsPt anxiety…how about rads’ anxiety?

Television celebrity, 62y

Eager to do an October breast awareness month feature

Wants to do live mammo appt and live reading of her exam

Yes, +fam hx

Not sure when was last exam or where…

JL is the breast imager to see her

JL made multiple requests for any outside prior exams…meeting resistance due to their rush timing

JL declined request to interpret exams on “live camera”

Finally got OSF on day of filming:

10/14, 9/12, 2/11, 10/08, 10/07

No prior US

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Case 5 -- sidestepping the FPs

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Case 5–Q

Screening mammo: 62 year old woman with strong fam hx. New to your institution. What would you like to do next?

A. Dense breasts, fam hx supplemental screening US

B. Breast MRI. More sensitive than screening US.

C. I see a clip. There are calcs. Need a biopsy.

D. Right exaggerated CC lateral, for partially seen asymmetry

E. Compare with prior outside films and path records. Everything I can get. And complete this exam.

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Case 5–Answer

Screening mammo: 62 year old woman with strong fam hx. New to your institution. What would you like to do next?

A. Dense breasts, fam hx supplemental screening US

B. Breast MRI. More sensitive than screening US.

C. I see a clip. There are calcs. Need a biopsy.

D. Right exaggerated CC lateral, for partially seen asymmetry

E. Compare with prior outside films and path records. Everything I can get. And complete this exam.

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Case 5 -- sidestepping the FPsLCC 10/15 c/w 2007 p stx

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Case 5 -- sidestepping the FPsLCC 10/15 c/w 2014 w spots (FP), 2007

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Case 5 --sidestepping the FPsRCC 10/15, XCCL, c/w 2011

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Case 6

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Case 6: “False positives”

“False positives”-avoidable kind?

unavoidable kind?

“False negatives”- also avoidable kind?

Do what you can about what/where you can optimize the process

Try not to have any regrets

You’re not done tilyou’re done. You’re the “operator.”

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Case 6: annual exam, 75 yo s/p L BCTWhat would you like to do?

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Case 6: 2015, 2016, & 2017Hx OSF, path 2013 invasive ductal and lobular features. 2013 surg path incl MD IDC 0.9cm

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Case 6: 2013 path reports

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Case 6–Q

You’ve compared with the prior two years. Convinced of a developing asymmetry at lumpectomy site. What to do next?

A. Rec surgical excision. This is highly suspicious.

B. Rec stereotactic guided biopsy. This is suspicious.

C. Do ultrasound, correlate. Anticipate US finding to guide biopsy. Left axilla, full ultrasound—would be good.

D. Do MRI next. US will be nonspecific. Not sure about biopsy.

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Case 6–Answer

You’ve compared with the prior two years. Convinced of a developing asymmetry at lumpectomy site. What to do next?

A. Rec surgical excision. This is highly suspicious.

B. Rec stereotactic guided biopsy. This is suspicious.

C. Do ultrasound, correlate. Anticipate US finding to guide biopsy. Left axilla, full ultrasound—would be good.

D. Do MRI next. US will be nonspecific. Not sure about biopsy.

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Case 6: Left spot views, US.Rec US core? False positive? False

negative? What to do next?

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Case 6: MRI… suspicious…What next?

MRI performed…

Suspicious brisk enhancement…

What next?

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Case 6: Excision– is sometimes also a

diagnostic step. Must see this to its full resolutionTrying to preempt false negative

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Case 6: “False positive”?Avoidable or unavoidable?Avoiding false negatives…

We’re not done til we’re done.Try not to have any (major) regrets

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Case 6: …2018, 2019…

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Cases 7 etc- if there’s time

To illustrate more points

Fast response, R or L, yes or no, etc

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Action plan: Black and white…and all shades of gray

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Screening/diagnostic

case

BI-RADS 1 Neg2 Benign

Not normal

Biopsy

BI-RADS 1 Neg2 Benign3 ST f/u

How?When?Ddx/dx?Mngmt?

Stx/US/MRg bxDBT/ ?CEDMgExcisionalIncisional bx

Imaging f/uClinical f/uSurgery Surgery etc

B9, concordantB9, discordant/ insufficient to explain finding“High risk lesion”….!!!!!!!!!Atypia…deps on which kind! Malignant, DCISMalignant, invasive

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Summary

Just do the best you can

And every day make your best even better

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Thank you@DrJiyonLeeJiyon.Lee@nyumc.org

Time for a few more cases?

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Our Breast Biopsies:

When to biopsy and how

…and when not and why

Cases 10 etc if time

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33yo with SBE palp for one week

20140124HP 22. sl5654

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33yo with SBE palp for one week

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33yo with SBE palp for one week

To do list: did mammoDo US, in full both breasts and L axCannot assume preop MR will happenL6:00 CBU= mod difft IDCStx post calcs

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33yo, BI-RADS 6, seg DCIS and IDC. What next?

L7:00 stx:HG DCIS, solid type w/ comedonecrosisand calcs

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33yo, seg DCIS and IDC. “Preop” MRI?

MRI: NME and mass with clip = BI-RADS 6, extensiveBlessing: negative right breast. Not even one ditzel.Time taken for full workup: is that delay to treatment? Or just good practice?“Measure”..several times…and cut once?

Surgery: total mast: poorly diff IDC, 1.7cm. Ext HNG DCIS. Diff SF, nonprolif FCC. LN 0/5.

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Vibrant 88 yo screening mammoDensity letter…opt in US

NYC, 2013Stable, dense mammoScreening US: 7mm irreg mass

USFNA: adenocarc with papillary features, assoc with necrosisLump: DCIS ING, ≥9mm, with necrosis and calcs; proliferative FCC

Is this “overdiagnosis”? MRI?

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Cases: Extremely dense is still an important mammogram to have (40y, 63y)

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Case 13

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Case: Density matters. But not only variable.How we use our other tools

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Case : Density matters. But not only variable.How we use our other tools

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Case : Density matters. But not only variable.How we use our other tools

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For what we do see

on mammo(For what we do not see

on mammo)

Breast US relative to mammo

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Case 14

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Case : Dense at any age and why CBE still matters

no matter what (81y)Relative “blind spots” potential, due to masking and anatomy

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Case : Dense at any age and why CBE still matters no matter what (81y)

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Case : Dense at any age and why CBE still matters no matter what (81y)

Declined surgery. Imaging follow up. Always hard to see (only on CC, US). Now also get bilateral screening US.

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2015 2016

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Case 15

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Case : 40yo baseline with left palp

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Case : 40yo with left palpFurther hx: CBE, “poss muscular”

US tech: “nothing focal”

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Case : 40yo with left palpPossibly “false positive” based on hx

Mammography suspicious but nonspecificUS initially possibly “false negative”

Pretest probability mattersAll modalities matter

Biopsy neededUSFNA atypia…= undersampling potential

US core biopsy needed= true positiveScreened full bilateral ultrasound too, and axillaStill need MRI—still diagnostic tool for full eval

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Action plan: Black and white…and all shades of gray

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Screening/diagnostic

case

BI-RADS 1 Neg2 Benign

Not normal

Biopsy

BI-RADS 1 Neg2 Benign3 ST f/u

How?When?Ddx/dx?Mngmt?

Stx/US/MRg bxDBT/ ?CEDMgExcisionalIncisional bx

Imaging f/uClinical f/uSurgery Surgery etc

B9, concordantB9, discordant/ insufficient to explain finding“High risk lesion”….!!!!!!!!!Atypia…deps on which kind! Malignant, DCISMalignant, invasive

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Summary

• The science and the art of medicine

• Best practices, appropriateness criteria… but we’re doctors with real intelligence, not artificial intelligence

• Smartly using all the tools we got

• SBE and CBE count too (espinterval CAs, not screening)

• Dense breasts: Not all dense breasts get cancer. Cancers arise in all density levels.

• Masking potential is the more immediate concern.

• “False positives”- get those OSF to avoid the avoidable FPs

• “False positives”- the unavoidable kind.

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Case 16

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6/03 @34, nursing. 8/03 ceased.

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3/30/06 @37, nursing.5/10/06, right palp concern

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Ages 38.5 to 40.5

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7/13/07 10/13/08 11/30/09

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Ages 41-44, perimenopausal

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11/30/10 12/7/11 12/3/12

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Ages 45- 46.5. What happened to patient?

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12/30/13 11/18/14 10/30/15

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10/31/16 @47.

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10/31/17 @48. 2D FFDM“2D” Mg= FFDM > Film Scr Mg

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10/31/17 @48. DBT (mid stack)

Opt in DBT. Opt out US.

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10/31/17 @48. DBT “s3D”

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10/31/16 2D. 10/31/17 2D, DBT, “s3D”

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“Baseline” mammo—which one counts for BD-based “risk” assessment?

Age of “baseline density” measurement matters.

Age 40 vs age 50

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Summary

Just do the best you can

And every day make your best even better

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Thank youJiyon.Lee@nyumc.org

Time for a few more cases?

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Multimodalitybreast Cases:

Using our complementary tools

More cases if there’s time

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Dense breast tissue…Worthy of respect

Limits sensitivity of mammography

Masking potential

Sensitivity for initial detection

Also ability to discern extent of disease

And identify additional pathology

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SBI

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CT: 2009TX: 2011VA: 2012NY: effect 1/2013 CA: effect 4/2013

HI: effect 1/2014MD: effect 10/2013TN: effect 7/2014AL: effect 8/2013NV: effect 1/2014

OR: effect 1/2014NC: effect 1/2014PA: effect ~2/2014NJ: effect 5/2014AZ: signed 4/2014

2014.5.2.

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More cases, if there’s time

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Case: Precision, yes…but sometimes don’t want to be perfect.

62yo, s/p left US core. Bx change decreased 5/18- 8/18Left 1:00 axis mass (inv ca) with clip

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Summary

Just do the best you can

And every day make your best even better

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Thank you for your attention! @DrJiyonLee

Jiyon.Lee@nyumc.org

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