Modern Imaging in Breast Cancer

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Modern Imaging in Breast Cancer

• Dr Linda Hacking
• Consultant Radiologist

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October is Breast Cancer Awareness Month

• Breast cancer is commonest cancer in UK
  (excluding non-melanoma skin cancer)
• 46,000 new cases per year
• 300 men, remainder women
• 80 over 50 years of age
• 1 in 9 women will get it in their lifetime

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Bad news/Good news

• Incidence has increased by 50 in last 25years
• 12,000 women and 70 men died from breast cancer
  in 2008
• 1,300 deaths in women under 50
• More than half deaths are in women over 70

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Bad news/Good news

• Since 1980s breast cancer death rates have fallen
  by one third
• Breast cancer is no longer the commonest cause of
  cancer death in women
• More than 8 out of 10 women survive beyond 5
  years (5 out of 10 in 1970s)
• Now twice as likely to survive 10 years as 40
  years ago.
• 2 out of 3 women survive beyond 20 years
• Breast cancer death rates falling faster in UK
  than rest of Europe

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Reasons for improvements in outcomes

• Screening
• Improved treatments (Tamoxifen etc)
• Improved cancer services including imaging

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Why are these improvements happening

• Breast screening?? (also increased diagnosis
  rate)
• Improved treatments (tamoxifen etc.)
• Overall improvements in care (including imaging)

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Breast Screening

• NHS Breast Screening Programme (NHSBSP)
• Began 1988-90
• Not Blackpool Victoria.
• Nearest centre Lancaster (vans, WGD)
• Invited for Mammograms from age 50-69
• Extended from 47-73 years from 2012 (target)
• Past upper age limit, option to arrange mammogram.

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Breast Screening

• Will cause increase in incidence of cancer
• Early cancers and pre-cancer (DCIS) are found
  that would never have led to a problem

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For Breast Screening

• One woman will be over-treated for every two
  lives saved
• 1000 lives a year saved
• Impact on population vs individual womans life.

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Against breast screening

• 10 of cancers are over-diagnosis and therefore
  over treatment
• It is impossible to estimate lives saved because
  of all other factors
• Impact on population vs impact on individual
  womans life

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Today we are talking about diagnosis
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The Symptomatic Breast Clinic

• Lump or thickening
• Change in size or shape
• Redness or rash in skin or nipple
• Indrawing of nipple
• Skin puckering or dimpling
• Lump in armpit

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Referral to Breast Clinic

• May simply need to see senior clinician- no
  further advice, no further investigations.
• Triple assessment/Double assessment
• See Senior Clinician (1)
• Imaging (2)
• Biopsy or needle test (FNA) (3)

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Modern Imaging and Biopsy

• Tests to be done at first clinic appointment for
  most patients
• Most patients will have a benign diagnosis
• Less than 1 in 10 patients attending our clinic
  will have a malignant diagnosis
• 9 out of 10 will be benign
• In new clinic, results for patients seen Monday,
  Tuesday available for Friday
• Wednesday, within a week

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Modern Imaging and Biopsy

• Quick accurate diagnosis for the majority of
  patients who will have a benign diagnosis
• As much information as possible about what we are
  dealing with in the minority if patients who have
  a malignant diagnosis
• Treatment can then be tailored to the individual
  patient

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Mammography

• Symptomatic patients
• Women gt35 years of age
• Uses x-radiation
• Invented in 1960s, modern type of machine 1969
• Still not in universal use 1986 (when I started
  in radiology)
• First unit Blackpool 1990 (Fylde Coast incl.NHS)
• Blackpool Victoria Mammography unit 1999.
• October 2010 Full Field Digital mammography

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Mammography

• Problems
• X-radiation
• Dense breasts
• Young women
• Men
• Implants
• No imaging 100 accurate

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Field Digital Mammography

• Better on all counts
• Dense breast
• Younger women
• Less radiation

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Ultrasound

• First imaging lt35, and men
• To clarify lumps and cysts on mammogram
• To do image guided biopsy
• To look at axilla (armpit)

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Ultrasound
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Cyst
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Fibroadenoma
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Ultrasound guided biopsy
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Ultrasound guided biopsy

• Needle guided into abnormality under direct
  vision
• Can be needle test (FNA)
• Or Core biopsy
• Uses local anaesthetic
• Takes 5-10 minutes
• a bit like getting ears pierced
• Complications- bruising, pain

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Ultrasound guided biopsy

• Quick very accurate results
• A patient specific individual plan if surgery
  required
• Tumour grade if malignant
• Hormone receptor status (Tamoxifen, herceptin)
• Size and extent of mass(es)
• Lymphnodes
• Test done Tuesday, results Friday

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Core Biopsy Needle
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Ultrasound guided biopsy
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Mammographic stereotactic biopsy

• Mass seen on mammogram, not on ultrasound
• Micro-calcification chalky bits- can be benign,
  can be malignant or pre-malignant (DCIS)
• No lump felt
• Standard core biopsy
• Vacuum assisted core biopsy
• Special devices

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Mammographic stereotactic biopsy

• Previously may have needed general anaesthetic
  surgery to remove abnormality
• Now outpatient procedure under local anaesthetic
• Most turn out to be benign

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Vacuum assisted biopsy
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Vacora vs 14G biopsy
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Sample can be x-rayed
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Breast MR (magnetic resonance)
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Breast MR

• Also major investment in breast coils and
  software for new MR scanner
• Increased comfort
• Ease of interpretation (software)

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Breast MR

• Recently in press
• In UK not used in every case
• Lobular carcinoma
• Multifocal carcinoma
• Problem solving when imaging/clinical/pathology
  do not match
• Doubts about mastectomy/ local excision
• Question of recurrence
• Implants

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Breast MRI

• Adds to planning of surgery

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So far

• We have been talking about diagnosis
• Imaging also helps during surgery

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Localisation of mass not felt

• Marker with ultrasound
• Wire with stereotactic mammography
• Mass can be x-rayed while patient still
  anaesthetised

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Excised specimen
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Also during surgery-Sentinel Lymph Node Biopsy
(SLNB)
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SNLB

• Small amount radioactivity injected into breast
• On morning before afternoon surgery
• Or afternoon before morning surgery
• Also blue dye in theatre
• Goes to first lymph node
• Surgeon uses probe in theatre
• No drain, much reduced complication rate compared
  with Node Clearance
• Seroma, lymphoedema, pain, numbness
• Overnight stay vs several day stay

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SLNB

• A small percentage will require further surgery
  once node examined in lab
• Nodes examined with ultrasound and FNA prior to
  surgery
• Not suitable for everyone

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Surgical probe
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The Future

• Tomosynthesis
• On table sentinel node diagnosis
• Answers about breast screening

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http//www.youtube.com/watch?vP5n3Avqqo2c
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To Summarise

• Blackpool Victoria has opened a brand new breast
  clinic
• We have the latest technology available for the
  best possible care for our patients
• The new clinic pathway for rapid access and
  diagnosis will benefit all of our patients
• Most patients will have a benign diagnosis
  delivered quickly

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• For the few patients who unfortunately have a
  malignant diagnosis
• They will be treated quickly, with all of the
  latest technologies available
• We should be able to upgrade for the future

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The outlook is good
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Thanks to the team!