Breast Imaging

1
Breast Imaging

• Olga Hatsiopoulou
• Consultant Radiologist
• Royal Hallamshire Hospital
• Sheffield Breast Screening Unit
• Sheffield Teaching Hospitals

2

• Screening
• Breast assessment in symptomatic FT clinics
• Case studies

3
(No Transcript)
4
Breast Cancer Why Screen?

• Improved outcome by treatment during the
  asymptomatic period
• Significant impact on public health

5
Mortality Reduction

• 50-69 y.o. mortality reduction 16-35
• 40-49 y.o. mortality reduction 15-20
• Lower incidence
• Rapidly growing tumors
• Dense breasts

6
Mortality Reduction

• Due to detection of cancers at smaller
  size/earlier stage
• Mammographically visible 3-5 years before
  palpable
• Increased detection of DCIS
• Early stage disease is curable

7
Diagnostic Accuracy of Screening Mammography

• Sensitivity in women gt 50 y.o.
• 98 fatty breast
• 84 dense breasts
• Specificity
• 82-98

8

• On the positive side, screening confers a
  reduction in the risk of mortality of breast
  cancer because of early detection and treatment.
• On the negative side is the knowledge that she
  has perhaps a one per cent chance of having a
  cancer diagnosed and treated that would never
  have caused problems if she had not been
  screened.
• Professor Sir Michael Marmot,
• UCL Epidemiology Public Health

9

• Symptomatic clinic / fast track clinic

10

• Triple assessment
• Multidisciplinary team approach
• Concordance

11

• Concordance of triple assesment
• P
• M
• U
• B
• Need for repeat biopsy or clinical core?

12
(No Transcript)
13
Digital mammography

• Quicker to do mammo almost instant output on
  monitor
• Better penetration of dense breast
• Digital manipulation of image

14
Digital mammography

• Proven to be better for younger/denser breasts
• Almost eliminates the need for magnification
  views can magnify digitally and still have full
  resolution

15

• Standard view mammography

• Cranio-caudal projection (CC)
• Medio-lateral oblique projection (MLO)

16
Calcification

• Most are benign and can be dismissed
• The goal is to identify new or increasing
  calcifications or those with suspicious morphology

17
Benign Calcifications
18
Malignant microcalcification

• Linear, branching casts comedo
• Granular/ irregular crushed stone
• Punctate - powdery

19
Architectural Distortion
20
Core biopsy

• All solid lumps and M3 MC get a biopsy
• Replaces fine needle aspiration in most cases
• 14g spring-loaded needle gun
• Well tolerated
• Main complication is haemorrhage

21
Core biopsy - histology

• Can give grade of cancers and presence of
  invasion
• Can give definitive diagnosis of benign lesions -
  avoid surgery

22
Ultrasound vs /stereo biopsy

• Ultrasound is used for all lesions visible on
  ultrasound quick and accurate
• Stereo biopsy is used for lesions not seen on
  ultrasound mainly microcalcification (mostly
  screening women)
• Same principle as stereoscopic vision two
  slightly different mammographic views allow
  calculation of depth

23
Prone biopsy table

• Woman lies prone on elevated table with breast
  dependent through a hope in the table
• Biopsy is done from underneath
• Access is 360 degrees

24
VAB

• Used with either ultrasound or stereo guidance
• Vacuum-assisted biopsy, single needle insertion,
  larger sample
• Allows better non-operative diagnosis, improved
  calc retrieval, more invasive cancer detection in
  DCIS

25
VAB biopsy

• 11g, compared with 14g for core biopsy
• 8g can be used to remove benign lumps
• Slightly greater risk of bleeding
• Well tolerated
• Can insert clip to mark site in case lesion is
  totally removed

26
Why use such a large bore?

• A larger sample is more likely to obtain a
  definitive diagnosis
• DCIS may be upgraded to invasive cancer
• ADH may be upgraded to DCIS
• Small/difficult lesions are more likely to be
  adequately sampled
• - Therapeutic excision of B3 lesions

27
Wire localisation

• Use U/S or stereo depending on how it is best
  seen
• Aim to get hook through the lesion
• Specimen x-ray after excision to confirm lesion
  remove

28
LIMITATIONS OF MAMMOGRAPHY

• As many as 5 15 of breast cancers are not
  detected mammographically
• A negative mammogram should not deter work-up of
  a clinically suspicious abnormality

29
FALSE NEGATIVES

• Causes
• Occult on mammogram (lobular CA)
• Finding obscured by dense tissue
• Technical
• Error of interpretation

30
RISK OF MAMMOGRAPHY

• Average glandular dose from a screening mammogram
  is extremely low
• Comparable risks are
• Traveling 4000 miles by air
• Traveling 600 miles by car
• 15 minutes of mountain climbing
• Smoking 8 cigarettes

31
Breast MRI

• Magnetic resonance imaging is used
• For problem solving
• For assessing the extent of lobular or extensive
  cancers
• For screening high risk women - high risk family
  history and women who have had mantle
  radiotherapy for Hodgkins disease
• Pre and post neoadjuvant chemotherapy
• For women with implants, to assess integrity

32
Detecting cancers on MRI

• Dynamic scan bolus injection of Gadolinium and
  rapid sequence of images
• Benign lesions can enhance
• Need to create a graph showing pattern of uptake
  over time
• Cancers show rapid uptake and washout

33
The axilla

• Ultrasound
• Level one nodes can be very low down
• Level three nodes may be best seen from an
  anterior approach through the pectoralis major
  muscle

34
Axillary node levels

• Level one
• lateral to lat margin of pectoralis major
• Level two
• under pectoralis minor
• Level three
• medial and superior to pectoralis minor, up to
  clavicle

35
Why scan/ biopsy the axilla?

• A pre-operative diagnosis of lymph node
  metastases will prompt the surgeon to go straight
  to an axillary node CLEARANCE
• A negative axilla on imaging will mean the woman
  has either
• Sentinel node biopsy
• Axillary sampling (four nodes)

36
Advantages of axillary biopsy

• Avoids two operations in women with positive
  nodes
• Alternative is axillary sample at time of WLE,
  then second operation for clearance

37
What about PET

• Indicated for the complex axilla/ brachial plexus
  problem
• May prove useful for looking for distant mets but
  not accepted primary method
• Resolution and specificity not good enough to
  look for nodes

38

• Importance of triple assesment
• MDT approach
• Concordance
• Challenges around breast screening
• A well informed patient