indications for breast imaging tests
TRANSCRIPT
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� Indications for breast imaging tests › Mammography, ultrasound, MRI
� Ontario Breast Screening Program (OBSP)
� BIRADS
� Rapid diagnostic unit
� Case examples
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� Goal is to find breast cancer early √ Better chance of treating successfully √ Less likely to spread √ May have more treatment options
� Breast cancer mortality in Ontario has declined between 1990 and 2009 › 37% ages 50-74 › 31.5 % for all ages › Due to screening and improved treatments
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� Cancer Care Ontario › 50-74 years of age every 2 years1
� Canadian Task Force on Preventive Health Care › 50-74 years of age every 2-3 years2
� American College of Radiology › 40-74 years of age every 1 year3
1 - https://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9514 2 - http://canadiantaskforce.ca/ctfphc-guidelines/2011-breast-cancer/systematic-review/ 3 - https://acsearch.acr.org/list
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� Non-OBSP › Physician referral required
� OBSP › No referral required › Women aged 50-74 can call their nearest
OBSP screening location to make an appointment
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https://www.cancercare.on.ca/pcs/screeening/breastscreening/obsp
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� Inviting women to participate in screening � Reminding patients of next screening test � Notifying participants of screening results � Tracking participants through the screening
processes � Evaluating program quality and
performance � Screening sites accredited by the Canadian
Association of Radiologists’ Mammography Accreditation Program
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� 50-74 years old* � No acute breast symptoms � No personal history of breast cancer � No current breast implants � No mammogram within the last 11 months * Over age 74, personal decision for
screening. MD can provide referral to OBSP for screening past this age.
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� Started in Ontario in 2011
� Annual mammography and MRI at a high risk screening centre (list on CCO website)
� Physician referral required (SB High-Risk Breast Clinic 416-480-6835)
� Eligibility for high risk screening › Age 30-69 › BRCA1/2 positive › 1st degree relative of mutation carrier and have declined
genetic testing › ≥ 25% lifetime risk of breast cancer › Chest radiation before age 30, at least 8 years previously
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� 0.4 mSv to each breast for mammography
� Chest x-ray 0.1 mSv
� CT head 2 mSv
� Natural background radiation 3 mSv
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� Breast symptoms including › New palpable lump › Nipple discharge › Redness of the skin that does not resolve › Tethering of the skin › Nipple inversion › Other symptom/sign suspicious for breast cancer
� Work-up of mammographic findings on screening mammogram- “call back”
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� Masses
� Asymmetry
� Distortion
� Calcifications
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� Extra views performed to assess findings on routine 2 views
› Spot compression views for masses and asymmetries
› Magnification views for calcifications
› Other specialized views for specific situations
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Lat mag CC mag
Stereotactic biopsy: Ductal carcinoma in situ
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CC spot MLO spot
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Invasive ductal carcinoma Lymph node neg
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� 1st method for women <30 yo or pregnant � Work-up of mammographic findings � Breast symptoms including › New palpable lump, breast or axilla › Nipple discharge › Redness of the skin that does not resolve › Tethering of the skin › Nipple inversion › Other symptom/sign suspicious for breast cancer
� Rule out abscess
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� 2nd look after MRI
� Known malignancy, multifocal or multicentric?
� Known malignancy, evaluation of axillary or supraclavicular nodes
� Male patient with palpable lump
� Imaging guidance for intervention
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� Whole breast and axilla › Suspicious mammographic finding or a
suspicious sonographic lesion found
� Targeted breast ultrasound › Screen detected isolated finding › Follow-up ultrasound for probably benign
lesions
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� Not performed routinely at academic institutions › Data is lacking for general population screening › Operator dependent › Time consuming
� Will perform in high risk patients who have contraindications to breast MRI
� Offered at some clinics
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IDC
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� Indications › Unilateral breast nipple discharge › Clear or bloody › Single duct › Reproducible
� Causes include › Intraductal papillary lesion › DCIS › Invasive ductal cancer
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CC MLO
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� Screening in high risk patients or screening of contralateral breast in patients with breast cancer
� Extent-of-disease � Problem solving � Post-lumpectomy with positive margins � Neoadjuvant chemo (before, during, after) � Assess for disease recurrence � Occult breast cancer (axillary
lymphadenopathy) � Implant integrity
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� Enhancement in the breast › Focus › Mass › Non-mass
� Other findings › Skin and nipple evaluation › Chest wall › Axillary lymph nodes
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IDC LN pos
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September 2014 June 2013
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IDC
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February 2015 June 2014 February 2015 June 2014
MLO views CC views
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Pectoralis Invasion
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� Performed for lesions not detected by either mammography or ultrasound
� ACR Guidelines: › For all centers performing MRI of the breast-
important to offer MRI guided biopsy
› If no biopsy capability- relationship with a facility that provides MR biopsy
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� BIRADS – Breast imaging reporting and data system
BIRADS
0 – Further work-up required
1 – Normal examination
2 – Benign findings
3 – Probably benign finding (≤2% chance of malignancy)
4 – Suspicious finding (2 to 95% chance of malignancy)
4a: >2 to ≤10%, 4b: >10 to ≤50%, 4c: >50 to <95%
5 – Highly suspicious finding (>95% chance of malignancy)
6 – Patient has biopsy proven malignancy
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� 6 month follow-up recommended � If stable, further 6 month, then 1 year follow-up
for a total of 2 years � Will remain BIRADS 3 until 2 year stability shown,
then becomes BIRADS 2 (benign mass)
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� Outpatient service � Single point of access for diagnostic
services � RDUs: › Concentrate and coordinate diagnostic
services › Provide information and support to patients › Help family doctors get access to diagnostic
tests for their patients › Expedite diagnosis and/or time to treatment
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� Any individual with an imaging abnormality or clinical finding that is highly suspicious for malignancy may be referred to the RDU
� BIRADS 4 or 5 on imaging, suspicious breast lump, clinical findings of inflammatory cancer, etc.
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� Launched May 2011 � 976 patients � Decrease in median
wait time from referral to diagnosis
58 days 10 days
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Referral Process Suspicious Finding
Patient arrives at RDU
Imaging and Core Biopsy
Communicating the Diagnosis
Pathology Analysis
Patient has consult in RDU
Patient’s imaging & core biopsy completed
Core specimen obtained
Pathology analysis complete
Pathology results available
Diagnosis communicated to patient by surgeon or surgical GPO & RN present with patient
Next Day Diagnosis
Sunnybrook Breast Rapid Diagnostic Unit (RDU): Work Flows
October 2011//al
1
2
3
4
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� Nursing assessment › Clinical history › Screened for distress › Clinical breast exam › High risk assessment › Patient education
� Breast Imaging › Mammogram › Ultrasound › Core biopsy › FNA (if required)
� Follow up instructions
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� Pathology result available the next afternoon
� Breast radiologist will review pathology result and dictate addendum with rad-path concordance for the surgeon prior to patient’s appointment
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� Patient returns that day to Breast Centre
� Receives diagnosis from breast surgeon or breast physician
� Preliminary discussion re: treatment options
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� See Sunnybrook website for referral form:
www.sunnybrook.ca search “breast RDU” � Contact Emily Walker
in NPB office - ext. 7938
� Contact RDU Nurse Navigator at ext. 85047
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