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MS10 - Lung Cancer Screening, Opportunistic Evaluation of Findings (ID 73)
- Event: WCLC 2019
- Type: Mini Symposium
- Track: Screening and Early Detection
- Presentations: 1
- Now Available
MS10.07 - Breast Evaluation (Now Available) (ID 3498)
15:45 - 17:15 | Presenting Author(s): Laurie Margolies
Opportunistic Evaluation of the Breast on Cross Sectional Imaging
Breast tissue is visualized on Chest CT, Chest MRI and to a limited extent on cross sectional imaging of the abdomen; much information about the breasts can be obtained. While cross sectional imaging does not substitute for mammography, for those women who have not had recent mammograms it may be the only opportunity for the breasts to be evaluated. Additionally, there are portions of the medial and posterior breast which can sometimes be seen to better advantage on cross sectional imaging.
Breast Density is a known risk factor for breast cancer development and can mask tumors on mammography. Traditionally, it has been taught that breast density can only be determined by mammography, but it can be reliably determined by evaluating the breasts on CT.[i] (figure shows a Chest CT of a woman with heterogenously dense breasts and corresponding cranio-caudal mammogram image) Reporting of breast density on Chest CT can better inform the patient of her risk and possible imaging strategies.
Masses and some calcifications can be seen on CT. Some are known and require no further evaluation, others are classically benign and also require no further evaluation, but some appear new or changed and do require dedicated breast imaging. By using a breast assessment and recommendatin score (BARCS) system to evaluate and report breast CT findings one can communicate to referring physicians what the next steps if any might be. This is similar to the BI-RADS system used for reporting mammography A BARCS score of 1 or 2 is analogous to the commonly used BI-RADS 1 or 2 and indicates that the findings are negative or benign and no special evaluation is needed. A CT-BI-RADS 2 might be used, for example, in the setting of a classic fibroadenoma. A mass that does not exhibit classic benign features, however, might be given a BARCS 0 and the patient referred for dedicated breast imaging (or review and correlation with prior breast imaging) as the imaging evaluation is incomplete. [ii] Some of these findings will be breast cancer (figure 2 shows a mass in the medial right breast that is easier to see on Chest CT than on mammogram where there is only a developing asymmetry - arrows). The opportunity to fully include and evaluate the breasts on cross sectional imaging should not be missed.[iii] Breast masses can also be an incidental MRI finding.[iv]
Dedicated breast imaging also has the opportunity to detect lung and other disease. Breast MRI, for example, typically includes portions of the lung and abdomen where osseous, lung, liver and renal lesions can be seen.[v] Mammography can detect lymphoma, metastatic melanoma and other systemic diseases such as congestive heart failure [vi] or even be the first indication of re-activation of Tuberculosis.[vii]Cardiovascular disease can manifest itself with breast arterial calcification evident on mammography; this often correlates with coronary artery calcification despite the differences in the pathogenesis of the calcifications. [viii]
Patients[ix] and providers[x] want interpreting radiologists to report on all the imaging findings; chest imagers have the opportunity to detect breast disease and promote appropriate evaluation of findings as well as to assist in personalizing breast cancer screening algorithms.
[i] Salvatore M, Margolies L, Kale M, et al. Breast Density: Comparison of Chest CT with Mammography. Radiology 2014 270:1, 67-73.
[ii] Margolies, LR, Salvatore M, Yip R, et al. The chest radiologist's role in invasive breast cancer detection. Clinical Imaging 2018, Volume 50, 13 - 19.
[iii] Salvatore M, Margolies, L, Bertolini, A, et al. The need to be all inclusive: Chest CT scans should include imaged breast parenchyma. Clinical Imaging 2018 Volume 50, 243-245.
[iv] Bignotti B, Succio G, Nosenzo F, et al. Breast findings incidentally detected on body MRI. Springerplus. 2016;5(1):781.
[v] Gao Y, Ibidapo O, Toth HK and Moy L. Delineating Extramammary Findings at Breast MR Imaging. Radiographics. 2017; 37:10–31.
[vi] Cao MM, Hoyt AC, Bassett LW. Mammographic Signs of Systemic Disease. RadioGraphics 2011 31:4, 1085-1100
[vii] Hwang E, Szabo J, Federman A and Margolies LR. Reactivation tuberculosis presenting with unilateral axillary lymphadenopathy. Radiology Case Reports. 2018: 13(6): 1188-1191.
[viii] Margolies L, Salvatore M, Hecht HS, et al. Digital Mammography and Screening for Coronary Artery Disease. JACC Cardiovasc Imaging. 2016 Apr;9(4):350-60.
[ix] Margolies LR, Yip R. Hwang E, et al. Breast Arterial Calcification in the Mammogram Report: The Patient Perspective. AJR Am J Roentgenol. 2019 Jan;212(1):209-214.
[x] Nasir K and McEvoy JW. Recognizing Breast Arterial Calcification as Atherosclerotic CVD Risk Equivalent. JACC: Cardiovascular Imaging Apr 2016, 9 (4) 361-363.