Dense en dan??
Ruud Pijnappel
Mammaradioloog
National Expert and Training Center
for Breast Cancer Screening
NABON BOOG 17 april 2014
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Are You Dense | Our Stories | Dr. Nancy Cappello's Story
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DR. NANCY CAPPELLO'S STORY
I did what the medical field and the countless number of cancer
advocacy groups told me. I ate healthy, exercised daily, had
yearly mammograms AND had no first-degree relative with breast
cancer. Little did I know at the time that there was information about my health and my life that
was being kept from me – the patient – and others like me. I call it the best-kept secret - but it
WAS known in the medical community. I have dense breast tissue – and women like me (2/3 of
pre-menopausal and 1/4 of post menopausal) have less than a 48% chance of having breast
cancer detected by a mammogram.
In November 2003 I had my yearly mammogram and my “Happy Gram” report that I received
determined “no significant findings”. Two months later at my annual exam in January, my doctor
felt a ridge in my right breast and sent me for another mammogram and an ultrasound. The mammogram revealed “nothing” yet the
ultrasound detected a large 2.5 cm tumor, which was later confirmed to be stage 3c breast cancer.
So on February 3, 2004 my life changed when I heard those dreaded words, “You have cancer.” I asked what most women would ask
– thinking that I was an educated patient - “Why didn’t the mammogram find my cancer”? It was the first time that I was informed that I
have dense breast tissue and its significance. What is dense tissue, I asked? Dense tissue appears white on a mammogram and
cancer appears white – thus there is no contrast to detect the cancer (It is like looking for a polar bear in a snowstorm). I asked my
physician why wasn’t I informed that I have dense breast tissue and that mammograms are limited in detecting cancer in women with
dense breast tissue? The response was “it is not the standard protocol.” So I went on a quest – for research – and found that there
have been 7 major studies with over 42,000 women that demonstrate that by supplementing mammograms with ultrasounds
increases detection from 48% to 97% for women with dense tissue. I also learned that women with dense tissue have a 5x greater
risk of getting breast cancer. We have double jeopardy – a greater risk of having cancer AND are less likely to have cancer detected
by mammography alone.
I endured a mastectomy, reconstruction, 8 chemotherapy treatments and 24 radiation treatments. The pathology report confirmed –
stage 3c cancer - because the cancer had traveled outside of the breast - to my lymph nodes. Eighteen lymph nodes were removed
and thirteen contained cancer – AND REMEMBER -
"On February 3, 2004, I was diagnosed with Stage 3c breast cancer
two months after receiving a "normal" mammography report. Less than
48% of women with Stage 3c breast cancer are alive after five years."
- Nancy M. Cappello, Ph.D.
a "normal" mammogram just weeks before. Is that early detection?
So, how many women are like me and had normal mammograms and may have a hidden intruder stealing their life? That question
has perplexed me since my diagnosis and I am on a quest to expose this best-kept secret of dense breast tissue to ensure that
women with dense breast tissue receive screening and diagnostic measures to find cancer at its earliest stage. Please join the breast
density inform movement by supporting the work of Are You Dense, Inc. to ensure that ALL women have access to an early breast
cancer diagnosis. Early Detection saves lives and spares the life-long anguish of families whose love-ones die prematurely from
breast cancer that goes undetected, even with yearly screening. Hence, cancer is not found until it is large enough to be felt and
subsequently determined to be at a later stage where survival is low.
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DENS
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Feiten /vragen
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Diagnostiek middels mammografie: lastig
Minder goede locoregionale controle?
Meer bestraling (Boost) nodig?
Overleving niet slechter
Eriksson, Breast Cancer Res. 2013 Jul
Gierach, JNCI 2012
Maskarinek, Breast Cancer Res. 2013 Jan
Saadatmand, BMC Cancer 2012
Zhang, Breast Cancer Res. 2013 Jan
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Dens breast
Risk 4-6 times
Densiteit
Afname
Sensitiviteit
RR
Neemt toe
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Richtlijn: Mammacarcinoom (2.0)
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Densiteit
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Diagnostiek
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Mammografie
Tomosynthese
3D echo
MRI
CESM
PEM
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Screening
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Bron: LETB 2014 (XIII)
Interval carcinoom
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Bron: LETB 2014 (XIII)
Mammografie
• ACR 4: 60-62% tumoren
• ACR 1: 80-87%
Carney, Ann Intern Med 2003
Bron: LETB 2014 (XIII)
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Diagnostiek
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Mammografie
Tomosynthese
3D echo
MRI
CESM
PEM
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Beperkingen van Mammografie
• Camouflage: mist kanker in ≈ 30%
• Nabootsen laesies: hoog verwijs %
– Additionele imaging (US, MRI, biopt)
– Hoge kosten
– Angst
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Overprojectie weefsel 2D
• Camoufleert laesies
• Drogbeeld laesie
Laesie overschaduwd in 2D
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Tomosynthese
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3D Mammografie
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Praktijk
2D FFDM
1 slice of DBT
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Tomosynthese beperkingen
Scantijd / bewegingsartefacten
Stralingsdosis 2x mammogram
Enorme dataset
Dubbele beoordelingstijd
Matig voor microcalcificaties
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Tomosynthese en densiteit
Ciatto et al Lancet Oncol 2013
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Tomosynthese en densiteit
Waldherr AJR 2013
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Tomosynthese en densiteit
Skaane Radiology 2013
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Conclusie Tomosynthese ACR 4
• EUSOBI oktober 2013
• RSNA december 2013
• ECR maart 2014
• EBCC maart 2014
Tomo betere sensitiviteit bij alle densiteiten
Dosis issue: synthetische 2D bij ACR 3 en 4 niet beter!
Geen specifieke cijfers voor ACR 4
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Diagnostiek
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Mammografie
Tomosynthese
3D echo
MRI
CESM
PEM
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Ultrasound ABVS
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Extremely Dense Tissue – Normal Study
3D Echo (ABVS)
Sensitiviteit: 97%
Fout positief: 19%
Giuliano, Clin Imaging 2013
Lander, Semin Roentgenol. 2011
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‘The diagnostic accuracy of the ABVS is almost identical to that of HHUS in breast imaging’
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Berg JAMA 2008 / Bae Radiology 2014
Detectie
Echo
• Toevoeging van US: 3,4 - 4,2/1000 meer
• 1/3 ACR4
• US only
• Retrospect mammo
81%
19%
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Maar……….
Time consuming minimaal 20
minuten per patient
FOUT POSITIEF
• 8,8% gebiopteerd op basis US
• PPV: 9%
Ter vergelijk PPV
mammogram screening: 67%
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Conclusie ABVS ACR 4
• EUSOBI oktober 2013
• RSNA december 2013
• ECR maart 2014
• EBCC maart 2014
ABVS nog geen plaats veroverd
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Diagnostiek
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Mammografie
Tomosynthese
3D echo
MRI
CESM
PEM
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Dense Trial
Normaal risicoprofiel
50-75 jaar via screening
ACR 4 (computed)
BI-RADS 1 of 2 screening
MRI 4.800 versus controlegroep 29.000
(Momenteel inclusie 1300 MRI)
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MRI Dense Trial
UMC Utrecht
AvL / NKI
VUMC
UMC Radboud
Jeroen Bosch (Den Bosch)
Maastricht UMC
Ziekenhuis Groep Twente (Almelo)
Albert Schweitzer Ziekenhuis (Dordrecht)
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Conclusie MRI ACR 4
• EUSOBI oktober 2013
• RSNA december 2013
• ECR maart 2014
• EBCC maart 2014
MRI?
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Diagnostiek
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Mammografie
Tomosynthese
3D echo
MRI
CESM
PEM
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CESM
• Contrast Enhanced Spectral Mammography
• Mammogram 2 energieniveau’s
• IV jodiumhoudend contrast
Lobbes et al. Clin Radiol 2013
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CESM image voorbeeld
A
Dank aan Marc Lobbes, radioloog MUMC
B
C
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CESM
- Geen informatie Densiteit
- Stralingsdosis: + 80%
- IV contrast
Lobbes et al Eur Radiol DOI 10.1007/s00330
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CESM vs MRI
• 25% ACR 4
• CESM >> Mammografie
• CESM ≈ MRI
Fallenberg et al Eur Radiol (2014) 24:256
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Conclusie CESM ACR 4
• EUSOBI oktober 2013
• RSNA december 2013
• ECR maart 2014
• EBCC maart 2014
Zeer goede initiële resultaten!
(Veelbelovend)
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PEM
• 18F-FDG intravenous
• Resting 60 minutes
• Image acquisition
- Duur
- Hoge stralingsdosis
- Langdurige compressie
(10-20 minuten per borst)
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Conclusie PEM ACR 4
• EUSOBI oktober 2013
• RSNA december 2013
• ECR maart 2014
• EBCC maart 2014
Duur
Hoge stralenbelasting
Langdurig onderzoek
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Take home ACR 4
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Anatomische naar functionele imaging
Mammo sensitiviteit: 60%
Tomo: ACR 4?
ABVS: Fout positief!
MRI: Dens Trial afwachten
CESM: zeer veelbelovend
PEM: duur, veel straling
• Geen bewezen alternatief voor mammogram
• Meedelen densiteit zinvol?????
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www.eusobi.org
Prof Monica Morrow (MSKCC, USA)
Prof Christiane Kuhl (Aachen, D)
Prof Elisabeth Morris (MSKCC, USA)
Prof Arnie Purushotham (King’s College, UK)
Prof Paul van Diest (UMCUtrecht, NL)
Dr. Gabe Sonke (NKI / AvL, NL)
Prof Fiona Gilbert (Cambridge, UK)
Prof Czernin (Los Angeles, USA)
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