Investigations OF breast cancer

PT--2

Content;-

1.INVESTIGATIONS FOR DETECTION

2.INVESTIGATIONS FOR STAGING

3.INVESTIGATIONS FOR TREATMENT

INVESTIGATIONS FOR DETECTION;-

MODALITIES;-1. MAMMOGRAPHY

2. TOMOSYNTHESIS

3. XERORADIOGRAPHY

4. THERMOGRAPHY

5. ULTRASOUND

6. ASPIRATION

7. MRI

8. MAMMOSCINTIGRAPHY or POSITRON EMISSION MAMMOGRAPHY

9. BIOPSY

MAMMOGRAPHYSTATS;-

Sensitivity-55%

Size-changes by 15-20%

False+ves-5-15%

False-ves-10%

• Detection of breast cancer by using low energy x-rays(less than which, is used for bone).

• Principle :- It identifies the areas of micro calcifications & tissue densities.

• Procedure:…..x-ray of superior and medial aspects,compression

• Malignant lesions show irregular densities and intra ductalcalcifications

• Benign lesions show well defined borders and peripheral calcifications.

• Types

• BIRADS SCORE-0-6

PROCESSING OF MAMMOGRAMPROCEDURE

NORMAL BREAST

BENIGN LESION

MALIGNANTLESION

TOMOSYNTHESIS

• Method of performing high resolution limited angle tomography at mammography dosage levels.

• High increase in sensitivity with little increase in exposure.

• Unlike ct rotation is 40 degrees and exposure is very less.

XERORADIOGRAPHY

STATS;- nearly same as that of mammography

Procedure;-it is same that of x-ray except the screen which is made up of selenium

It is useful for untrained eyes

It is outdated technique not used now a days.

THERMOGRAPHY

• PRINCIPLE usually many malignant tumours are hot . so by identifying these hot spots we can identify the tumour.

• FALSE+VES;-INFECTION

• FALSE-VES;-SOME MALIGNANT TUMOURS WHICH ARE NOT HOT

• MAIN USE;-differ b/w benign and malignant.

ULTRASOUNDPrinciple:-

A non-invasive imaging technique that uses sonic energy in the frequency range of1-10MHz.

USG is non-ionizing form of energy which is safe even in pregnants,children.

Echoes of USG beam gives info. about size,shape&internal structure of organs&masses.

USG IN BREAST CANCER• APPEARANCE;-

1. Cysts-fluid filled lesions-no internal echo

2. Benign-Solid lesions-smooth and well defined borders

3. Malignant-jagged borders

Earlier the sensitivity of USG used to be very less but the advent of advanced techniques like gray scale echographyhas made it very useful

BENIGN CYST MALIGNANT LESION

ASPIRATIONDone in case of cystic lumps of breast.

Most of the times they are benign.butif aspirateis,

1. Blood stained

2. Mass does not completely disappear on aspiration

3. Recurrences are there,

send the fluid to FNAC and the mass for BIOPSY,if +veresults come mastectomy or lumpectomy is done.

MRI

Principle• It uses a pulsed radio frequency beam in presence of strong magnetic field to obtain images of high quality.

•Nuclei of any atoms with odd number of nucleons behave as small magnets.

• in the diagram…….

•Hydrogen nuclei are used as they-1.abundant in body

•2.Sensitive to phenomenon of magnetic resonance

In breast cancercontrast enhancement by gladolinium chelate is used.

given i.v 0.1milli mol/kg.

Tumours are characterised by

a) Hypervascularity

b) Increased capilary permeability

c) Increased interstitial space

these are all due to neovascularisation property of tumours.it will lead to pooling of contrast agent in that area.

• It used to have a high sensitivity but low specificity.

• But the problem has been overcome by new techniques likedynamic imaging andhigh resolution static contrast enhanced imaging

• Now the sensitivity is 95% and the specificity is 86%.

• Advantages;-

1. High sensitivity

2. Shows the exact size

3. Response to chemotheraphy can be known

4. Distinguish scar from recurrence

5. Useful for staging as it shows nipple areolar or pectoral or nodal infiltration,detects multi-centered foci and tumuor size.

PRINCIPLE OF NUCLEAR MEDICINE

• It depends on the selective uptake of diff compounds by diff orans of body.

• These compounds are labelled with radioactive substance of sufficient energy level to detect it out side the body.

• Technitium99 is a near ideal isotope which is non toxic and inexpensive.

• Mechanism for uptake;-

1. Blood pooling-cardiac scan

2. Phagocytosis –liver scan e.t.c.

POSITRON EMISSION TOMOGRAPHY

Nuclear scan of breast is called mammoscintigraphy.

X-rays and MRI identify anatomical changes,while PET helps in identifying molecular changes even before the anatomical changes.

• It is of two types 1)single gamma and2)dual gamma

• Excellent sensitivity for tumours >1cm

• Poor sensitivity for tumours <1cm ,medially located and non palpable tumours.

• Materials used are 99TCsestambi and 99TCtetrafosmin.

• If the scan is taken in different directions like CT it is called PET.

BIOPSY•For definate diagnosis of malignancy

•Types;-

1. Needle biopsy

2. Drill biopsy(>1cm)

3. X-ray guided biopsy(>3mm)

It helps in 1.search for metastasis

2.Discussion for mastectomy

DRILL BIOPSY NEEDLE BIOPSY

INVESTIGATIONS FOR STAGING;-

MODALITIES;-

1. FOR T—TECHNIQUES FOR DETECTION MAINLY MRI

2. FOR N- LYMPHO SCINTIGRAPHY,CT

3. FOR M-BONE XRAY,BONE SCAN,LIVER SCAN,CHEST X-RAY, BIOCHEMICAL STUDIES.

CHEST X-RAY;-

• Simplest method for observing visceral metastasis.

• Lung involvement is of two types;-

• 1.blood borne-multiple nodular lesions ,late onset of symptoms ,detect 1-2 cm

• 2.thru lymphatics-diffuse lesion,early onset of symptoms,>2cm as they blend with other mediastinalstructures

LYMPHOSCINTIGRAPHY

• It is Nuclear scan of lymph nodes.

• It is done preoperatively to know the extent of invasion.

• Material is 10-15MBQ of 99TC labelled nanocoll

• 0.2 ml is injected subdermally on the lesion.

• Helps for identification of SLN and its differentiation from other groups.

BONE XRAY

• Bones are the most common site of metastasis in breast cancer

• Most commonly involved are pelvis and spine.

• Lumbar >thoracic >sacrum >cervical.

• 4 types of changes in bone;-

• 1.osteolytic

• 2.osteoblastic.

• 3.Without any associated damage

• 4.combination

BONE SCAN

• PROCEDURE;-i.v injection of radioactive 99mTCphosphonate and bisphosponate.overall body scan by rectilinear scanner.

• Routine skeletal survey is done by bone scan followed byx-ray of the abnormal areas.

• Healing fractures,osteomyelitis,pagets disease show false+vehot spots .they have to be differentiated by x-ray .

LIVER SCANSulphur colloid labelled99mTECHNITIUM is injected i.v and scan is done by rectilinear scanners.

It is taken up by the reticulo endothelial system.Focal filling defects indicate metastasis.

Lesions<2cm cannot be identified.butthey are found frequently

CTFor metastasis in mediastinal and retroperitoneal lymph nodes.

BIOCHEMICAL STUDIES;-

1. ALKALINE PHOSPATASE for bone and liver.

2. GAMMA GLUTAMYL TRANSAMINASE for liver.

3. CARCINO EMBRYONIC ANTIGEN along with liver scan.

4. URINARY STEROIDS like aetiocholanolone in relation to 17-hydroxy corticosteroids.

5. URINARY HYDROXYPROLINE-due to collagen destruction.

INVESTIGATIONS FOR TREATMENT;-

MODALITIES;-

1. SENTINAL NODE BIOPSY

2. LYMPHOSCINTIGRAPHY

Sentinal node biopsy

• Sentinal node indicates first node encountered by the tumour cells and its histological status predicts the status of distant lymph nodes.

• ADVANTAGES;-

• 1.minimally invasive technique,morbidity and cost are very low.

• 2.gives an idea of involvement of axillary lymph nodes

• 3.obviates the need for axillary node dissection in all breast cancer cases without compromising staging information.

All good things come to an end…… GRACIAS..///:-)

FOR UR PATIENCE ND ACCEPTANCE - -- M.Uma sai (PT-2)