Breast Cancer
Conditions
Keywords
mammography, contrast enhanced spectral mammography
Brief summary
This study is designed to investigate the diagnostic accuracy of Contrast Enhanced Spectral Mammography (CEDM) in predicting early neoadjuvant therapy response and pathologic complete response (pCR) compared to mammography. Patients diagnosed with invasive breast cancer with available mammography and ultrasound imaging are eligible for the study. Eligible patients will be imaged at baseline (before initiation of neoadjuvant chemotherapy or endocrine therapy), early (2-4 cycles of neoadjuvant therapy) and late (after completion of neoadjuvant chemotherapy or endocrine therapy) timepoints with mammography. CEDM will be done within 2 weeks of the specified timepoint. Additionally, a survey of subject experience with CEDM and other pre-operative imaging will be collected after CEDM is performed.
Detailed description
The use of neoadjuvant systemic therapy in the treatment of breast cancer patients is increasing beyond the scope of locally advanced disease. Imaging provides important information in assessing response to therapy as a complement to conventional tumor measurements via physical examination. Tumor response to neoadjuvant therapy can also provide prognostic information. The attainment of pCR after completion of neoadjuvant therapy and surgical resection is associated with improved disease-free survival. This correlation is especially strong for Triple-receptor negative and human epidermal growth factor receptor 2 (HER-2) positive breast cancer. Studies of neoadjuvant therapy have used a variety of methods for assessing tumor response. Currently, there are no established clinical practice guidelines for how best to assess tumor response to neoadjuvant therapy. Typically, patients undergo conventional breast imaging such as mammography and ultrasonography (US) and physical examination, and dynamic contrast-enhanced breast magnetic resonance imaging (DCR-MRI) in selected cases. Contrast Enhanced Digital Mammography (CEDM) is a novel imaging technique, which allows digital mammography to be used with contrast enhancement to depict cancers that would otherwise be occult on standard unenhanced mammography. CEDM is performed with and without intravenous iodine contrast, using the dual energy subtraction technique. Compared with mammography and US, CEDM improves the sensitivity for breast cancer detection without decreasing specificity. CEDM digital detector has higher spatial resolution than MRI, revealing details that are approximately 10 times better. In contrast to the rapid washout in MRI, enhancement on CEDM in fact persists for at least 10 min after contrast agent infusion. Today CEDM is available commercially for clinical use. It is estimated that over 200,000 CEDM examinations have been performed to date in both research and clinical settings. CEDM costs significantly less compared to MRI. Furthermore, longer time delays between contrast injection and CEDM exposure could result in stronger enhancement and hence better visibility compared to MRI, especially given the much higher spatial resolution of digital mammography. It is unknown whether CEDM can improve the sensitivity of mammography in the early assessment of neoadjuvant therapy response. We hypothesize that CEDM is superior to mammography and ultrasound in assessing early response, and pre-surgical residual cancer after neoadjuvant therapy, and when performed, non-inferior to MRI in assessing the residual disease using the metrics of pCR and residual cancer burden (RCB).
Interventions
PROCEDUREDigital Mammography
Digital Mammography enhanced with an iodinated contrast agent
DRUGLow Osmolar Contrast Material, 300-399 Mg/Ml Iodine Concentration, Per Ml
Injection of low osmolar contrast material during the digital mammography exam
Sponsors
University of Texas Southwestern Medical Center
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
DIAGNOSTIC
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Ipsilateral intact biopsy-proven breast cancer clinical stage T1-T4 (by imaging) * Available mammography and ultrasound imaging of the existing index cancer, with orthogonal measurements * Prior history of ipsilateral or contralateral breast cancer, presenting with a new primary or recurrent disease * Patients who were determined to be candidates for either neoadjuvant chemotherapy or neoadjuvant endocrine therapy by the treating physician * Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and for days following completion of study participation. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately.
Exclusion criteria
* History of ipsilateral mastectomy * Women who already started neoadjuvant chemotherapy or endocrine therapy * Woman who may be pregnant or nursing an infant * Prior history of anaphylactic or anaphylactoid reaction to any contrast. * Prior allergy to iodine or iodinated contrast. * Impaired renal function measured by estimated glomerular filtration rate (eGFR) \< 60 milliliters per minute. * Patients with known distant metastasis.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Sensitivity of Predicting pCR (Pathologic Complete Response) for CEDM | 4 to 6 months from initiation of neoadjuvant therapy until final surgery | Sensitivities in predicting pCR will be calculated for CEDM and measured as AUC |
| Sensitivity of Predicting pCR (Pathologic Complete Response) for Mammography | 4 to 6 months from initiation of neoadjuvant therapy until final surgery | Sensitivities in predicting pCR will be calculated for mammography measured as AUC |
| Specificity of Predicting pCR (Pathologic Complete Response) for CEDM | 4 to 6 months from initiation of neoadjuvant therapy until final surgery | Specificity of predicting pCR will be calculated for CEDM and measured as AUC |
| Specificity of Predicting pCR (Pathologic Complete Response) for Mammography | 4 to 6 months from initiation of neoadjuvant therapy until final surgery | Specificity of predicting pCR will be calculated for mammography and measured as AUC |
| Diagnostic Accuracy of Contrast-enhanced Mammography in Assessing pCR or Non Response | 4 to 6 months from initiation of neoadjuvant therapy until final surgery | ROC analysis will be used to assess the diagnostic performance of CEDM. The Area under the receiver operating characteristic (ROC) curve (AUC) will be compared. A leave-one-out cross validation algorithm will be used to reduce bias from overfitting. |
| Correlation of Residual Tumor Size With Pathologic Size | 4 to 6 months from initiation of neoadjuvant therapy until final surgery | Spearman's rank correlation will be used to measure the association between final pathologic and imaging tumor size |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Breast Cancer Patients Patients with ipsilateral intact biopsy-proven breast cancer
Digital Mammography: Digital Mammography enhanced with an iodinated contrast agent
Low Osmolar Contrast Material, 300-399 Mg/Ml Iodine Concentration, Per Ml: Injection of low osmolar contrast material during the digital mammography exam | 6 |
| Total | 6 |
Baseline characteristics
| Characteristic | Breast Cancer Patients |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 0 Participants |
| Age, Categorical Between 18 and 65 years | 6 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 6 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 2 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) White | 4 Participants |
| Region of Enrollment United States | 6 participants |
| Sex: Female, Male Female | 6 Participants |
| Sex: Female, Male Male | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 6 |
| other Total, other adverse events | 0 / 6 |
| serious Total, serious adverse events | 0 / 6 |
Outcome results
Primary
Correlation of Residual Tumor Size With Pathologic Size
Spearman's rank correlation will be used to measure the association between final pathologic and imaging tumor size
Time frame: 4 to 6 months from initiation of neoadjuvant therapy until final surgery
Population: The number of participants with outcomes in our trial was limited to only three. Furthermore, none of the patients had pCR -hence none of the cases have the reference standard needed to calculate this parameter.
Primary
Diagnostic Accuracy of Contrast-enhanced Mammography in Assessing pCR or Non Response
ROC analysis will be used to assess the diagnostic performance of CEDM. The Area under the receiver operating characteristic (ROC) curve (AUC) will be compared. A leave-one-out cross validation algorithm will be used to reduce bias from overfitting.
Time frame: 4 to 6 months from initiation of neoadjuvant therapy until final surgery
Population: The number of participants with outcomes in our trial was limited to only three. Furthermore, none of the patients had pCR - hence absence of reference standard end point precludes this assessment.
Primary
Sensitivity of Predicting pCR (Pathologic Complete Response) for CEDM
Sensitivities in predicting pCR will be calculated for CEDM and measured as AUC
Time frame: 4 to 6 months from initiation of neoadjuvant therapy until final surgery
Population: The number of participants with outcomes in our trial was limited to only three. Furthermore, none of the patients had pCR -hence none of the cases have the reference standard needed to calculate this parameter (sensitivity).
Primary
Sensitivity of Predicting pCR (Pathologic Complete Response) for Mammography
Sensitivities in predicting pCR will be calculated for mammography measured as AUC
Time frame: 4 to 6 months from initiation of neoadjuvant therapy until final surgery
Population: The number of participants with outcomes in our trial was limited to only three. Furthermore, none of the patients had pCR -hence none of the cases have the reference standard needed to calculate this parameter (sensitivity).
Primary
Specificity of Predicting pCR (Pathologic Complete Response) for CEDM
Specificity of predicting pCR will be calculated for CEDM and measured as AUC
Time frame: 4 to 6 months from initiation of neoadjuvant therapy until final surgery
Population: The number of participants with outcomes in our trial was limited to only three. Furthermore, none of the patients had pCR -hence none of the cases have the reference standard needed to calculate this parameter (specificity).
Primary
Specificity of Predicting pCR (Pathologic Complete Response) for Mammography
Specificity of predicting pCR will be calculated for mammography and measured as AUC
Time frame: 4 to 6 months from initiation of neoadjuvant therapy until final surgery
Population: The number of participants with outcomes in our trial was limited to only three. Furthermore, none of the patients had pCR -hence none of the cases have the reference standard needed to calculate this parameter (specificity).