Breast Histopathology : Mammography

Dr. Charles Hitchcock, MD, PhD

Mammographic Screening

• Primary Learning Objective– Discuss the identification and management of

individuals at risk for breast cancer• Secondary Learning Objective

– Discuss the use and significance of mammography as a tool for breast cancer screening

– Discuss issues related to breast cancer screening

Mammography remains the Gold-Standard, First-Line Breast Imaging Screening Modality

• Screening Mammography • Asymptomatic patient• Negative clinical breast exam• Starting at age 40; annually thereafter

• Diagnostic Mammography• Symptomatic patient• Suspicious findings on clinical breast exam

Mammographic Screening for Breast Cancer

Warner, E. Breast Cancer Screening New Eng J Med 365, 1025-1032, 2011.

Breast Density vs. Mammography Findings

Mammography Terminology• Analog Mammography (Plain Film

Mammography) - x-ray beam directly captured on a film cassette.- outdated and obsolete.

• 2D Digital Mammography (Digital Mammography)- x-ray beam captured on digital detector → converts x-ray

beam into electronic signal → transferred to a computer → viewed on high- resolution monitor → allows for > image manipulation.

- can allow for 30% to 40% decrease in radiation dose.- should be used as Gold-Standard method for screening

and diagnostics.

Digital vs. Conventional Mammography

Analog versus 2D Digital MammogramLess Dense Breasts

Analog Mammogram

AnalogMammogram

2D Digital Mammogram

2D Digital Mammogram

More Dense Breasts

Mammography Terminology

• 3D Digital Mammography (Breast Tomosynthesis)- camera moves over breast, taking multiple-angle

images, creating a 3D image, and thus minimizing the impact of overlapping breast tissue.

- allows for even > image manipulation.- earlier detection of smaller breast cancers.

- be care in ordering! → it may NOT get paid for!

Screening for Breast Cancer

Warner, E. Breast Cancer Screening, New J Med 365, 1025-1032, 2011.

Mammography

• Three mammographic abnormalities that are suspicious for cancer include:

• Mass• Microcalcifications• Asymmetric Density

Mammography

Average-size lump found by woman practicing occasional breast self-exam (BSE)

Average-size lump found by woman practicing regular breast self-exam (BSE)

Average-size lump found by first mammogram

Average-size lump found by getting regular mammograms

Microcalcifications

Mammography

Clinical Finding Infiltrating Carcinoma

(%)

Infiltrating CarcinomaMean (cm)

Nodal Metastases

(%)

DCIS(%)

Microcalcifications on Mammogram

26 0.6 6 71

Density onMammogram

94 1.1 14 4

Palpable Mass 94 2.4 58 2

After Table 23.1 in Robbins

BIRADS:Breast Imaging, Reporting, and Data System

• Originally designed to utilize standardized descriptors to characterize mammographic findings, including:– Densities/Nodules/Masses/“Asymmetries”– Calcifications– Associated Changes (skin thickening, skin

retraction, nipple retraction, architectural distortion, axillary adenopathy)

– Categorized findings as BIRADS Category 0-5– Later adapted for image reporting of Ultrasound

and MRI

BI-RADSTM Mammogram Categories

Category Assessment Recommendation

0 Incomplete assessment Additional Imaging Needed

1 Negative Routine screening

2 Benign / stable findings Routine screening

3 Probably benign Short interval follow-up

4 Suspicious abnormalityBiopsy recommended / urged

5Highly suggestive of malignancy

Appropriate action to be taken

Breast Ultrasound• Best performed in a targeted-fashion to a particular

area of interest in the breast and not in a screening fashion to the entire breast.

• Breast modality to distinguish cystic versus solid lesions.

• Best modality to characterize solid lesions.• Useful in detecting and defining intraductal lesions

in the evaluation of suspicious nipple discharge.

Breast MRI• Should be utilized

selectively in appropriate selected patients.

• Two categories for utilization:– Potential Diagnostic

Utilities– Potential Screening

Utilities

Breast MRI - Diagnostic Tool• Evaluating a patient with a “difficult” clinical breast exam and

dense breasts on mammography. • Characterizing breast anatomy in the absence of a

mammographic or ultrasound lesion (BI-RADS 2 breast imaging) in a patient with a clinically suspicious finding on clinical breast exam.

• Evaluating clinical concerns in a breast with an augmentation / implant.

• Evaluating clinical concerns a mastectomy patient with implant reconstruction.

• Evaluating clinical concerns a mastectomy patient with autologous tissue flap reconstruction.

• Ruling out multicentric ipsilateral disease or concurrent contralateral disease in a patient with a newly diagnosed breast cancer.

• Monitoring tumor response to preoperative neoadjuvant systemic chemotherapy in a patient with newly diagnosed breast cancer.

• Annual screening of any patient with a documented hereditary breast cancer gene mutation. YES! YES! YES!

• ???Annual screening of a patient with a strong family history of breast cancer but who has had documented negative genetic testing??? CONTROVERSIAL?

• ???Annual screening of a patient with a strong family history of breast cancer but who has declined genetic testing??? CONTROVERSIAL?

• ???Annual screening of a patient with a personal history of breast cancer??? CONTROVERSIAL?

• ???Annual screening of a patient with a personal history of radiation therapy to the chest for another type of cancer, such as Hodgkin’s disease, when treated between the ages of 10 and 30 years old??? CONTROVERSIAL?

Breast MRI - Screening Tool

Recap of Key Points• Mammography is best in post-menopausal women

because of reduced density.– It identifies abnormal microcalcifications in most ductal

carcinomas in-situ that can’t be identified on physical exam– It is capable of identifying smaller lesions that would go

undetected by palpation.

• Use ultrasound in a targeted manner not as a screening method

• MRI uses include: –Hereditary breast cancer gene mutation–Patients with implants–R/O multicentric disease–Monitoring chemo effects before surgery

Mammography Quiz

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