In The Nam of God In The Nam of God

Role of imaging in diagnosis

early breast cancer

Dr. Mehri Sirous

* IMAGING *

The standard techniques used for breast

imaging are:

1. Screen film x-Ray mammography.

2. Real-Time ultrasound.

3. Other new techniques include:

MRI

Color Doppler

Contrast ultrasound

Digital Mammography

Scintimammography

Mammography can find abnormalities

between one and three years before

they can be felt.

Because the inherent attenuation differences

between normal & diseased breast tissues is so

small , high quality mammography required.

Although mammography is the most

sensitive exam available for detecting

small breast ca.

False Negative Rate is 5-10%

Mammography

Breast cancers are most likely to develop in

dense tissue, where they are most difficult to

detect.

Mammograms can result in false negative

readings (particularly in younger women, who

have dense breast tissue) or false positive

readings

* Clinical history and examination

* Combination imaging

• Mammography standard views

• supplementary mammographic views

• Local compression views

• magnification views

• ultrasound

* Needle biopsy

* F.N.A.C

* Or core biopsy

False negative rate ↓

Review of old films :

If old films are available, comparison is

important to search for any changes.

It is a good idea to compare studies that are

of least 2 years apart.

Mammography tests are not perfect.

Only the part of the breast that extends from the

body can be imaged. This makes it easier to

get an accurate picture of a larger breast than a

smaller breast !

It also may be difficult to detect abnormalities

that exist in the breast tissue adjacent to the

chest wall.

Up to 20 percent of breast cancers are

missed by mammograms, according

to the National Cancer Institute

Full-field digital mammography (FFDM).

Recently approved by the U.S. Food and

Drug Administration (FDA), this technique

involves taking digital images of the breast.

Digital images are captured electronically

and can be viewed on a computer. Their

magnification, brightness and contrast can

be adjusted and enhanced to better reveal

abnormalities.

Advantages to having digital mammography

Elimination of process or artifacts

Contrast enhancement

Ability to perform invasive procedures faster

Potentially better resolution of breast tissue for women younger

than 50 years

Reduce examination time for patients

Increased production of examinations

Images are immediately available

Digital Mammography Detected

up to 28% More Cancers in

Certain Groups:

• Women under the age of 50

• Women with heterogeneously

dense or extremely dense breast

• Women that are premenopausal

or perimenopausal

Greater Access

• The mammogram can be

read where ever theradiologist is located

• This also allows for physicians

to consult with their peers

Review of Prior ImagesBefore Procedure

Incomplete assessmentCategory 0:

Additional imaging evaluation and/or comparison to prior mammograms needed. Possible abnormality may not be completely seen or defined and will need more tests, such as use of spot compression, magnification views, special mammogram views or ultrasound.

Complete assessment

Category 1: Negative No significant abnormality to report.

Breasts appear the same (symmetrical) with no masses, architectural distortion or suspicious calcifications.

Category 2: Benign (Noncancerous).Also a negative

mammogram, but with description of a finding known to be benign, such as benign calcifications, intramammary lymph nodes or calcified fibroadenomas. This ensures others viewing the mammogram will not misinterpret benign finding as suspicious.

Category 3:

Probably benign - follow-up suggested, Findings have

a very high probability (greater than 98%) of being

benign. Findings are not expected to change. Follow-

up with repeat imaging usually done in six months

and regularly thereafter until finding is known to be

stable (usually at least two years). Procedure helps

avoid unnecessary biopsies while allowing for early

diagnosis of a cancer should suspicious area change.

Category 4:

Suspicious abnormality - biopsy suggested Findings could be cancer, with sufficient concern to recommend biopsy. Findings in this category have a wide range of suspicion levels. Some – though not all – physicians may divide category further:

4A: finding with low suspicion of being cancerous

4B: finding with intermediate suspicion of being cancerous

4C: finding of moderate concern of being cancerous, but not as high as Category 5

Category 5:

Highly suggestive of malignancy – appropriate action necessary .Findings look like and have high probability (at least 95%) of being cancer. Biopsy is strongly recommended.

Category 6: Confirmed Malignancy – Appropriate Action Should Be Taken .Used for findings on mammogram already

determined to be cancerous by a previous biopsy. 

Breast ultrasound At the minimum, a 7.5 MHZ linear array probe

should be used

The original role of breast sonography is in the

differentiation of cystic and solid lesions

The role of ultrasound complements both clinical

examination and mammography

Ultrasound plays an important role in the triple

assessment of symptomatic lesions the dense breast

It is the examination of choice in young

women and is valuable in the assessment

of mammography ‘ dense’ breast

BIRADS 1 Sonographically normal tissue that cause mammographic or clinical abnormality.

BIRADS 2 Benign entities (intramammary LN, ectatic duct ,simple cyst ,definitively benign solid such as lipoma)

BIRADS 3 Probably benign(<2% risk) complex cyst ,small intraductal papilloma ,fibroadenoma)

BIRADS 4a Mildly suspicious(3%-49% risk)

BIRADS 4b Moderately suspicious(50%-89% risk)

BIRADS 5 Highly suspicious( >90% risk )

Management Rules

BIRADS 1 ,2 Routine screening

BIRADS 3 Three choices

short interval sonographic F.U

image guided needle biopsy

surgical biopsy

BIRADS 4a ,4b,5 Require biopsy

The type of imaging chosen depends principally on which method (ultrasound or mamography) shows the lesion clearly.

Ultrasound is used for cysts and most soft – tissue lesions

Mammography is used for microcarcification and for soft – tissue lesions that are not seen or are poorly visualized on ultrasound particularly distortions

Imaging – guided practical procedures

Ultrasound – guided procedures

1. Cyst aspiration (simple cysts with symptoms)

2. Abscess aspiration (simple, unilocular abscess)

3. Ultrasound – guided FNAC (solid lesions)

4. Ultrasound guided core biopsy

(small solid lesions)

Mammography – guided procedures

Stereotactic – guided FNAC or core

biopsy

Preoperative localization of

non – palpable lesions.

Indication for breast MRI Breast MRI is the technique of choice in the

differentiation between postoperative scarring and

local recurrence

It has an important role in the assessment of the

indeterminate mass because of its very high

sensitivity for malignancy though at present, core

biopsy is a more cost – effective approach.

It is very accurate in the local staging of breast cancer in difficult cases (very dense breasts, mammographically occult tumours, suspected multi- focality or multicentricity and suspected chest wall involvement).

It is the technique of choice in the evaluation of implant integrity and detection of cancer in the augmented breast.

It is also accurate in the differentiation of axillary recurrence and brachial plexopathy post radiotherapy.

Indication for breast MRI

Breast MRI appears highly accurate in the

assessment of response to neoadjuvant and

primary chemotherapy, predicting ulti- mate

response before changes in tumour volume and

differentiating between residual tumour and

fibrosis.

The place of breast MRI in screening high-risk

patients has yet to be established

Indication for breast MRI