Mammografin Brstcentrum SS

Ariel Saracco, verlkare

The Imaging Diagnostic Approach

to Breast Lesions

Breast cancer in EU 2009

every 1.5 minute a woman in the EU develops a breast cancer

every 6.5 minutes results in a death in the EU due to breast cancer

yearly increase rate: 1.7% in the last 10 years

Breast cancer worldwide

heterogeneous, progressive disease that develops from within the

glandular tissue spreads to the surrounding tissue

10% of all new cases of invasive cancer diagnosed in the world

25% of cancers diagnosed in women (most common among them)

1.4 millon new cases (2008)

460,000 deaths (2008)

second most common cause of death from cancer

Breast cancer in Sweden 2009

7,049 new cases per year (5-6/1000 from screening program)

1,500 patients die yearly from this disease

30% mortality reduction in the last 29 years due to:

early and better diagnosis

(improving the performance of screening programs, cyto/pathology)

prevents death in the medium to long term

reduces the incidence of advanced disease/node positive disease

improvement in treatments

(surgery, prompt delivery of high quality oncology adjuvant and neo-adjuvant therapy)

Diagnostic imaging methods in breast

diseases

Mammography (Mx): sensitivity 74 - 95 %specificity 89 - 97 %

Ultrasound (US): complementary method to mammography

Mx + US: sensitivity (98%)

Magnetic resonance (MRM): high sensitivity (99%), but low specificity (70%)

5+2 specific indications

Nuclear medicine (NM): high sensitivity in detecting lymph nodes (sentinel node metastases)

MBI (Molecular Breast Imaging)

Diagnostic imaging methods in breast

diseases

Mammography (Mx)

first image modality in screening and clinical due to its high sensitivity/specificity as a method per se for breast cancer detection

x-ray conventional or digitalmammography

does not detect all malignancies (limitation in dense breasts)

Ultrasound (US)

most important complementary method to mammography

no ionizing method

better assessment of the already detected cancers - diagnosis

better assessment of palpable lesions not seen on mammography (ex. dense breasts)

lymph nodes investigation - staging

excelent for interventional procedures

fast, cheap and comfortable for the patient

Screening M vs. Clinical M

Screening M

asymptomatic women invited

to have a mammogram(77% attendance rate in Sweden)

detection tool

Clinical M

patients with symptoms or

control, sent (GP,

gynecologist, surgeon,

oncologist) for a

mammo/US + ev.biopsy

diagnostic tool

Triple diagnosis

clinical examination

imaging methods (Mx/US)

biopsy (FNA, core biopsy, vacuumbiopsy)

Diagnostic imaging methods in breast diseases - ages

Mammography

Screening

40-49 years old/18 mth

50-74 years old/24 mth

Clinical

from 25 years old whenever its needed and if its possible to perform...

Diagnostic imaging methods in breast diseases - views

Mammography

Screening

2 views

(1) CC (craneo-caudal) 0

(2) MLO (mediolateral-oblique) 45 to 60

Diagnostic imaging methods in breast diseases - views

Mammography

Clinical

3 views

(1) CC

(2) MLO

(3) LM (latero-medial) 90

localizations (1, 2 and/or 3)

magnifications (1, 2 and/or 3)

rolled or rotated views (1, 2 and/or 3)

Cleopatra view (exagerated cc)

Eklund view (pushn pull technique for implants)

Diagnostic imaging methods in breast diseases extra views

Diagnostic imaging methods in breast diseases - scoring

ACR/BI-RADS

0 need additional imaging evaluation (or comparison w/previous exams)

1 normal (or negative)

2 benign finding

3 probably benign finding, FN 2% (6-12-24 month follow up-no biopsy)

4 a,b,c suspicious of malignancy (biopsy?)

5 highly suggestive of malignancy (biopsy)

6 known biopsy-proven malignancy (treatment)

Swedish score system (Mx/US)

0 no exam performed (ex. mastectomy)

1 normal

2 benign finding

3 slightly suspicious of malignancy (FN

Diagnostic imaging methods in breast diseases Mx findings

masses (or densities)

calcifications

architectural distortions

asymmetries

Diagnostic imaging methods in breast diseases masses

benign, indeterminate and malignant

localizations, roll views or magnifications; in various views

looking for shapes, borders, different densities, halo sign

Diagnostic imaging methods in breast diseases masses, benign

Diagnostic imaging methods in breast diseases masses, cancer

Diagnostic imaging methods in breast diseases benign/cancer

Diagnostic imaging methods in breast diseases calcifications

benign, indeterminate and malignant

magnifications in at least 2 views (1-3) on the calcifications and surrounding areas

looking for shapes, densities, distribution and extention

Diagnostic imaging methods in breast diseases calc., benign

Diagnostic imaging methods in breast diseases calc., benign

Diagnostic imaging methods in breast diseases calc., cancer

Diagnostic imaging methods in breast diseases calc., cancer

Diagnostic imaging methods in breast diseases ductography

bloody or clear secretion

from one pore of the nipple

0,1-0,4 ml of Iodine CM

magnifications x3

cytology of the secretion

Diagnostic imaging methods in breast diseases ductography

Diagnostic imaging methods in breast

diseases ultrasound

L17-5/L12-5 MHz transducer (Philips iU22)

correct gain and parameters for each

individual breast tissue

complete coverage of the breast

special attention in the subareolar region

at least 2 perpendicular views and

compression on + findings

doppler if needed

regional lymph nodes status if needed

Breast ultrasound (B-US) cancer

diagnosis

staging (TNM)

biopsies (IP)

Breast ultrasound (B-US)

better assessment of the tumor seen on the

mammogram (size)

better assessment of the tumor not-seen on

the mammogram (palpable, dense tissue)

better assessment of the disease process,

usually not well define on the

mammogram (dense tissue)

diagnosis

Breast ultrasound (B-US)

diagnosis

staging (TNM)

size

multifocality / multicentricity

regional lymph nodes status

axilla

FIC

FSC

IMC

Breast ultrasound (B-US)

diagnosis

staging (TNM)

biopsies (IP)

FNAB (tumor and lymph nodes)

Core biopsies (tumor, lymph nodes)

Vacuum-assisted biopsies (breast)

Diagnostic imaging methods in breast diseases US findings

echogenicity

margins

RAP (retro-acustic phenomena)

Diagnostic imaging methods in breast diseases (cyst)

Diagnostic imaging methods in breast diseases (fibroadenom)

Diagnostic imaging methods in breast diseases (fibroadenom)

Diagnostic imaging methods in breast diseases (cancer)

Diagnostic imaging methods in breast diseases (cancer)

Diagnostic imaging methods in breast diseases (cancer)

Diagnostic imaging methods in breast diseases US summary

US criteria for breast cancer ( 4 mm)

solid (almost anechoic)

wide and jagged borders (irregular)

lack of compressibility

vertical orientation (taller than wide)

Diagnostic imaging methods in breast diseases US summary

Case 1 37 years old with a palpable lump caudalt in the left breast. Mx score 5

Case 2 58 years old, palpable mass at 10 oclock, dense breast tissue in mammography. MX score 5

Breast ultrasound - remarks

operator dependent

vast experience/ability required

previous knowledge of what we are looking for

required

proper interpretation of the image observed

Dynamic contrast-enhanced MRM

indications

clinical staging before breast conservation surgery (multifocality/multicentricity), specially in ILC, DCIS HNG

screening of women with the risk of hereditary breast cancer (BRCA1-2)

detection of occult breast carcinoma (CUPS)

imaging after breast conservation surgery (scar? vs. recidiv tumour?)

evaluation of the patients with breast implants

monitoring the effect of neoadjuvant chemotherapy (?)

in vivo assessment of tumor aggressiveness and predicting prognosis (?)

Dynamic contrast-enhanced MRM

remarks

high sensitivity (99%) but low specificity (70%)

BI-RADS (scoring system: morphology and functional)

margin characteristics and time-to-peak are the most useful and

independant predictors of malignancy

no indication to evaluate the extention of the DCIS I-LNG, yet...

False positives

proliferative changes (HRT, ADH, ALH, sclerosing

adenosis), FA, post-op hyperemia, fat necrosis,

infection, hormonal cycle (2nd week)

False negative

low/intermediate grade DCIS, low grade invasive

lobular, tubular or mucinous carcinoma, LCIS, recent

chemotherapy (suppresses enhancement)

Dynamic contrast-enhanced MRM

remarks

Summary

There is no imaging method in the breast than can find 100% of the malignancies

All three modalities-clinical examination, imaging methods and cyto/pathology- give a very good approach (triple diagnosis)

This is a team work between surgeons, radiologists, cyto/pathologists and oncologist

Thank you!