breast imaging use of tomo in kwh e fung

Use of Breast Tomosynthesis Experience in

Kwong Wah Hospital

Dr Fung Po Yan Eliza

Specialist in Radiology

Associate Consultant, Well Women Clinic, Honorary Associate Consultant, Department of Radiology

Kwong Wah Hospital

Disclosure

•  Neither I nor my immediate family members have a financial relaAonship with a commercial organizaAon that may have a direct or indirect interest in the content.

Tung Wah Group of Hospitals Breast Screening Service

Workflow of Screening mammography

Screening Mammogram

( Double Reading )

Abnormal ( Cat 3 or above )

Refer MulDdisciplinary

MeeDng

Early Follow up ( Phone

consultaDon )

Normal /benign ( Cat 1 and 2 )

Follow up in 2 years

( ConDnuous care )

AHendance of Screening Mammogram

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Attendence

1993-‐3163 MMG 2000-‐10283 MMG 2011-‐18781 MMG

Tomosynthesis AccquisiAon

Hologic

Dense Breasts

Digital Breast Tomosynthesis FFDM Tomo

•  Tube head moves in a continuous motion 15°(± 7.5°)

around the breast

•  A total of 15 low-dose projection images are acquired at 1 projection/degree

•  Tomo scan in 4 seconds

•  Combo mode ( 3D + 2D ) in 13 secs

•  Reconstruction images are displayed in 1mm slices at 90µm resolution

Hologic-‐Dimensions

Digital Breast Tomosynthesis

PotenAal Benefits of DBT •  MicrocalcificaAons: -‐ DM slightly more sensiDve in detecDon ( Spangler ML : AJR 2011; 196(2):320-‐4 ) -‐ DBT equal or greater clarity ( Kopans D : Breast J 2011; 17:638 )

•  Non-‐calcified lesions evaluaAon: -‐ Superior cancer visibility and conspicuity ( Andersson I : Eur Radiol 2008; 18: 2817 ) -‐ DBT superior to DM (Margarita L : Radiology Jan 2013 , 266, 89-‐95 )

PotenAal Benefits of DBT

•  Specificity/Reduce recall rate: -‐  Increased when used adjuncDvely with DM ( Elizabetha A. Radfferty : Radiology 2013 : Volume 266: 104-‐11 ) ( Michell MJ : Clinical Radiology 2012 ; 67:976-‐981 ) ( TM Svahn : BJR 85, 2012 e1074-‐1082 ) (Ciabto S : Lancet Oncol 2013 Jun; 14(7):583-‐9) ( Hass BM : Radiology 2013 Jul 30 Epub )

Oslo Tomosynthesis Screening Trial

•  ProspecDve Study •  Nov 2010-‐Dec 2011 •  Oslo University , 8 radiologists •  Independent Double Reading with consensus •  12621 screening MMG •  50-‐69 year old •  Screen biennially

Radiology: Volume 267: Number 1—April 2013


Screening DM(2D)+DBT(3D)

DM Independent double reading

Arm A DM

Single reading

Arm B DM + CAD

Single reading

DM+DBT Independent double reading

Arm C DM + DBT

Single Reading

Arm D SyntheDc DM + DBT

Single reading

Methods

•  5 point raDng system (1=normal/benign, 2-‐5=>posiDve )

•  For all cases >2 in at least one arm => ArbitraDon meeDng

•  Published data in Arm A ( DM ) and Arm C ( DM + DBT )

•  Among 12621 cases, 121 malignancy found

Outcome ( Rates per 1000 ) 2D vs Combo ( 2D + 3D )

DetecDon Rate * 6.1 8.0 +27

False PosiDve Rate* ( before arbitraDon )

61.1 53.1 -‐15

PosiDve PredicDve Value ( ajer arbitraDon )

29.1% 28.5% -‐2

Time*

45s

91s

+100

2D %

*Significant p=< 0.001

2D+3D


DetecDon Rate *

6.1 8.0 +27


61.1 53.1 -‐15


29.1% 28.5% -‐2

Time*

45s

91s

+100

2D %


2D+3D


DetecDon Rate * 6.1 8.0 +27


61.1 53.1 -‐15


29.1% 28.5% -‐2

Time*

45s

91s

+100

2D %


2D+3D

Breast Density

2D 2D+3D Difference

Faby 4 6 2

Scabered 26 36 10

Heterogenous Extreme

23 3

34 5

11 2

Invasive Cancer ( no of Ca ) 2D vs Combo ( 2D + 3D )

2D 2D+3D Difference

Total number Invasive Cancer

77 56

101 81

+24 +25

Grade I <15mm

17 37

32 59

+15 +22

LN negaDve 44 63 +19

Invasive Cancer ( no of Ca ) Tumour Grade

2D 2D+3D Difference

Total number Invasive Cancer

77 56

101 81

+24 +25

Grade I Grade II

17 29

32 35

+15 +6

Grade III 9 13 +4

Invasive Cancer ( no of Ca ) Lesion Size

2D 2D+3D Difference

<10mm 11-‐15mm

27 37

36 59

+9 +22

16-‐19mm >20mm

6 12

5 15

-‐1 3

Invasive Cancer ( no of Ca ) Lymph nodes status

2D 2D+3D Difference

LN negaDve LN posiDve Unknown

44 9 3

63 13 5

+19 4 2

Invasive Cancer ( no of Ca ) Radiological finding

2D 2D+3D Difference

Circumscribed mass

7

9

+2

Spiculated mass

28

37

+9

Architectural distorDon

8

16

+8

Asymmetric density

4

4

+0

CalcificaDons Mass with calcificaDons

6 3

6 9

+0 +6

In situ Cancers ( DCIS ) 2D vs Combo ( 2D + 3D )

2D 2D+3D Difference

Total number 21 20 -‐1

CalcificaDons 20 19 -‐1

Mass+calcificaDons

1 1 0


•  Significant increase in cancer detecDon rates

•  ParDcularly useful for invasive cancers •  Simultaneous decrease in false posiDve rates

Experience of Kwong Wah Hospital •  Hologic Dimensions installaDon in Oct 2011

•  Study Period : February to May 2012 •  Call back for compression view ( CC or MLO view ) => Tomosynthesis

•  Not used for calcificaDon workups •  No preselecDon of paDents •  261 sets performed

•  Compression Pressure •  RadiaDon dose •  Reason for call back ( Focal asymmetry/Mass/ Architectural distorDon/Others )

•  Radiologists grade the Tomo vs FFDM (Superior/Equal/Inferior)

•  Need to call back if Tomo is available

Experience of Kwong Wah Hospital

Results •  Reduce recall rate by 61.3% •  Especially useful in evaluaDng-‐focal asymmetry •  Superior ( 64% ), Equal ( 34 % ) , Inferior ( 2% ) •  Comparable breast compression ( 111% ) •  Slight increased entrance radiaDon dose ( 129% )

•  PaDent ( lible to no difference ) •  Physician ( posiDve ) •  Radiographer ( fast adopDon ) •  Radiologist ( learning curve, extra-‐Dme , performance affected by the network , dedicated mammo viewer, memory space)

•  Two-‐ views DM vs DBT ( 100MB vs 250 MB )

Experience of Kwong Wah Hospital

Asymmetric Density

Fibroadenoma

Invasive Carcinoma

Invasive Carcinoma

USG

Invasive Carcinoma

Tubular Carcinoma

•  Yung Mui Hing Video

Invasive Ductal Carcinoma

SyntheDc mammogram

•  Generates from the Tomo data •  No addiDonal radiaDon dose •  Emulates 2D image:

– Facilitates comparison to old films

•  Maintains important details from tomosynthesis slices –  Interpreted in combinaDon with tomosynthesis images

Dose reduction in digital breast tomosynthesis (DBT) screeningusing synthetically reconstructed projection images: anobserver performance study

David Gur, ScD1, Margarita L. Zuley, MD2, Maria I. Anello, DO2, Grace Y. Rathfon, MD2,Denise M. Chough, M.D.2, Marie A. Ganott, M.D.2, Christiane M. Hakim, M.D.2, LuisaWallace, MD2, Amy Lu, MD2, and Andriy I. Bandos, PhD3

1University of Pittsburgh, Department of Radiology, Radiology Imaging Research, 3362 FifthAvenue, Pittsburgh, PA 152132Department of Radiology, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 152133University of Pittsburgh, Graduate School of Public Health, Department of Biostatistics, 130DeSoto Street, Pittsburgh, PA 15261

AbstractRationale and Objectives—Retrospectively compare interpretive performance of syntheticallyreconstructed two-dimensional images in combination with DBT versus FFDM plus DBT.

Materials and Methods—Ten radiologists trained in reading tomosynthesis examinationsinterpreted retrospectively, under two modes, 114 mammograms. One mode included the directlyacquired FFDM combined with DBT and the other, synthetically reconstructed projection imagescombined with DBT. The reconstructed images do not require additional radiation exposure. Wecompared the two modes with respect to “sensitivity”, namely recommendation to recall a breastwith either a pathology proven cancer (n=48) or a high risk lesion (n=6); and “specificity”, namelyno recommendation to recall a breast not depicting an abnormality (n=144) or depicting onlybenign abnormalities (n=30).

Results—The average sensitivity for FFDM with DBT was 0.826 versus 0.772 for syntheticFFDM with DBT (difference=0.054, p=0.017 and p=0.053 for fixed and random reader effect,respectively). The fraction of breasts with no, or benign, abnormalities recommended to berecalled were virtually the same: 0.298 and 0.297 for the two modalities, respectively (95%confidence intervals for the difference CI= −0.028, 0.036 and CI = −0.070, 0.066 for fixed andrandom reader effects, correspondingly). Sixteen additional clusters of micro-calcifications(“positive” breasts) were missed by all readers combined when interpreting the mode withsynthesized images versus FFDM.

Conclusion—Lower sensitivity with comparable specificity was observed with the testedversion of synthetically generated images versus FFDM, both combined with DBT. Improvedsynthesized images with experimentally verified acceptable diagnostic quality will be needed toeliminate double exposure during DBT based screening.

© 2011 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.Correspondence: David Gur, ScD, University of Pittsburgh, Department of Radiology, Radiology Imaging Research, 3362 FifthAvenue, Pittsburgh, PA 15213, Phone: 412-641-2513, Fax: 412-641-2582, [email protected]'s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

NIH Public AccessAuthor ManuscriptAcad Radiol. Author manuscript; available in PMC 2013 February 1.

Published in final edited form as:Acad Radiol. 2012 February ; 19(2): 166–171. doi:10.1016/j.acra.2011.10.003.

NIH

-PA Author Manuscript

NIH


NIH


114 MMG SyntheDc view+DBT vs DM+DBT Lower sensiDvity Comparable specificity Missed clustered microcal

Image Comparison DM Tomo Slice SyntheDc

Details are maintained DM SyntheDc Tomo Slice

Conspicuity of CalcificaDons SyntheDc DM Tomo Slice

SyntheDc FDDM

Future DirecDon

•  In place of the convenDonal FDDM •  FDA Approval ( May 2013 ) •  Less radiaDon and paDent discomfort •  DiagnosDc Quality ? •  Oslo Tomosynthesis Screening Trial •  DM+CAD vs SyntheDc view+DBT •  RSNA 2013 ?

email : [email protected]

Thank you

Acknowledgment

•  Department of Radiology, KWH •  Dr Chun Ying LUI •  Dr Kimmy KWOK •  Dr William WONG •  Dr Julian FONG •  Dr Kevin LAU •  Ms Daisy SIU •  Mammography Team, KWH •  Breast Centre, KWH •  Dr Miranda CHAN •  Dr Marcus YING •  Dr Yolanda CHAN •  Well Women Clinic •  Dr Tung Yeung LEUNG •  Dr Rebecca CHUNG •  Dr Wai Ka HUNG •  Dr Hang Yi So •  Dr Hiu Wing Hong •  Pathology Department •  Dr Kong Ling MAK

The End

breast imaging use of tomo in kwh e fung

Health & Medicine