BREAST IMAGING

Introduction and History Breast cancer is 2nd only to lung cancer as cause of death in women Very treatable with early detection! 1st innovation since radical mastectomy introduction in 1898 In 1913, radiographic appearance of breast cancers was first reported Mammography became a reliable diagnostic tool in 1950s when industrial grade x-ray film introduced

1960’s – Xerography introduced – much lower dose Research conducted in 1970s clearly showed mammography to be essential part of early diagnosis 1975 – High speed/resolution film introduced by DuPont 1992 – MQSA implemented (Mammography Quality Standards Act)

WHAT IS MAMMOGRAPHY? Mammography is a special type of X-ray imaging used to create detailed imaging of the breast. It uses low-kV X-ray, high contrast, high-resolution film and an X-ray system designed specifically for imaging the breasts. 46

Definition of breast cancer: Cancer that forms in tissues of breast, usually ducts (tubes that carry milk to nipple) and lobules (glands that make milk). Occurs in both men and women (male breast cancer is rare)

Risk v. Benefit Breast cancer in United States in 2009 (estimated): New cases: 200,000 (female); 2,000 (male) Deaths: 40,000 (female); 400 (male) Us population 306 million in 2007- 133 deaths /million Mortality risk from mammography induced radiation is 5 deaths/ million pts. using screen film mammography More risky to refuse mammography ( especially if the patient has symptoms and signs of breast ca ) !!

Breast Cancer: Why Screen? High prevalence Improved outcome by treatment during the asymptomatic period Significant impact on public health

Mortality Reduction Due to detection of cancers at smaller size/earlier stage Mammographically visible 3-5 years before palpable (the lump could be visible 3-5 years before palpable ) Increased detection of DCIS Early stage disease is curable

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

MAMMOGRAM 1- SCREENING MAMMOGRAM 2- DIAGNOSTIC MAMMOGRAM

Screening Versus Diagnostic Tests Screening evaluates a population of ASYMPTOMATIC people at risk for disease ( family history for breast cancer,...etc ) Goals High sensitivity for disease Low false negative rate Lower specificity acceptable

Diagnostic Accuracy of Screening Mammography Sensitivity in women > 50 y.o. 98% fatty breast (females in this age their breasts are more fatty Because of this masses are easy to see on mammogram , unlike younger females their breasts are more dense fibro glandular and here difficult to see masses ) 84% dense breasts Specificity 82-98%

SCREENING VS DIAGNOSTIC MAMMOGRAPHY Screening mammography Uses X-rays to image the breast to identify abnormalities that may represent cancer Patients asymptomatic Generally, the radiologist does not see films until the patient has left the radiology department

SCREENING VS DIAGNOSTIC MAMMOGRAPHY Patients with breast signs or symptoms (palpable lump, pain, nipple discharge, skin retraction ) Patients with abnormality detected on screening mammogram Performed under the supervision of a radiologist Additional specialized mammographic views ( magnification , compression )

Screening Mammography Consists of two images of each breast Craniocaudal (CC) Medial-lateral-oblique (MLO)

When you want to specify the location of the disease on the mammogram : 1- right or left breast. 2- CC view or MLO view ( if you see the pectoralis major muscle so it’s a MLO view) 3-in CC view : you should determine if it is in the lateral ( outer ) or medial ( inner ) side. 4- in MLO view: you should determine if it is in the upper or lower side.

1  it’s a pectoralis major muscle , so it’s a MLO view . 2 3 4 5 1  it’s a pectoralis major muscle , so it’s a MLO view . 2  its an upper portion of MLO view of the breast . 3  it’s a lower portion of MLO view of the breast . 4  it’s the lateral ( outer ) portion of CC view of the breast . 5  it’s the medial ( inner ) portion of CC view of the breast .

CC 2 masses in the Left breast , CC view , one in the lateral portion of the left breast . And the second in the medial portion of left breast. 19

Views of mammogram 22

MLO view, mass in the left breast , in the upper portion . 23

CC Rt Lateral Outer Medial Inner

MLO Rt Upper Lower

NORMAL MAMMOGRAM CC MLO 26

CC

MLO

THE SCREENING MAMMOGRAM: What are radiologists looking for? Masses Calcifications Other findings ( scars , skin thinking ) When we want to see the lesion we should see the 2 views ( CC , MLO ) to determine in which quadrant it .

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

Case 1 55 y.o. Screening mammogram

CC view , mass in the left breast , in the medial side ( inner ) , speculated lesion( indication of malignancy )

MLO view , for the previous patient , the mass in the left side of the breast , in the upper portion . In the right side , in the upper part you can see opacity it’s a dense fibro glandular tissue ( normal )

Case 2 47 y.o. Screening mammogram

CC view , well defined radiopaque , in the right breast , in the lateral side of the breast.

Same patient Well defined circular lesion in the right breast in the upper portion of the breast.

Screening mammography summary + +/- - Widely available Low cost Low risk/minimal discomfort High sensitivity and specificity/low induced cost Demonstrate decreased mortality High reproducibility

Imperfect, but the only screening test proven to significantly decrease breast cancer deaths Will likely remain the primary screening test for breast cancer MRI may be useful in addition to mammographic screening in certain populations MRI useful when you cant see lesions by mammogram and you are highly suspect there is a lesion ( because clinically patient has signs and symptoms of breast ca , positive family history , discharge ) so we can use MRI to see more details.

ACS Screening Guidelines: Average Risk Annual mammography age 40 and older ( in Jordan every 2 years for asymptomatic patient and her age is more than 40 ) Reduction in mortality by 30-50% Annual clinical breast exam age 40 and older Q 3 years age 20-40 Self breast exam optional

ACS Screening Guidelines Annual mammography earlier if mother or sister diagnosed with breast cancer ( if there is first relative degree of breast, ovarian or uterine ca (her sister , mother , Aunt ) , in this case mammogram screening should start10 years prior to age of relative’s diagnosis … ex : mother was diagnosed as a breast ca case at age of 45 year , so here daughter should start screening at age of 35 years.) MRI if at high risk for breast cancer

SCREENING VS DIAGNOSTIC MAMMOGRAPHY Patients with breast signs or symptoms (palp lump, pain, nipple d/c) Important for breast signs or symptoms that clinicians specify Location (side (right or left ) , clock-face ( by ultrasound we can divide the breast to 12 clock , distance from nipple(far or near ) Size and shape Diagram

DIAGNOSTIC MAMMOGRAPHY Asymptomatic patients with abnormality detected on screening mammogram (“recalled”) Performed under the supervision of a radiologist Additional specialized mammographic views Spot compression +/- magnification

VIEWS OF DIAGNOSTIC MAMMOGRAM Main views: 1- Mediolateral oblique. 2- Craniocaudal. Additional views: 1- Compression view for areas of suspicious masses or asymmetric breast tissue. 2- Magnification view for suspicious calcifications. 43

Compression view : It is used to distinguish between the presence of a true lesion and an overlap of tissues, as well to better show the borders of an abnormality or questionable area or a little cluster of faint micro calcifications in a dense area. 

After doing mammogram and in both views of mammogram there is no masses but there is asymmetric breast tissue and one more denser than the other breast , here you suspect something , so you need more views to make a diagnosis … you do compression view : 1- if the breast tissue separate and allows better visualization of the breast tissue in that area , so its normal and there is only condensation lesion of breast tissue 2- if the breast tissue doesn't separate and appears as it appears on views of mammogram , so it’s a mass.

Compression view 46

Magnification 47

Case 1: Patient Recalled From Screening

Screening Mammogram

Diagnostic Mammography Work-up: Screening Recall Is the finding real? Spot Compression Magnification Localize in two dimensions Is the finding suspicious for malignancy Feature analysis What Next?

Spot Compression Mag True Lateral Spot Compression Mag MLO After doing spot compression view , the mass doesn't disappear so it’s a real mass ( true mass) .

Breast Ultrasound: Indications and Imaging Role Mammographically detected masses Palpable masses after mammography (most) Initial study for palpable masses in : Pregnant ( safe , no radiation ) Lactating ( because mammogram is very painful ) Less than age 30 ( breast in this age contains more dense fibro glandular tissue , so difficult to detect masses. Cyst versus solid Solid masses: benign versus malignant features Fluid appears generally black (anechoic)

Firstly , we do mammogram and if there is any pathology , we detect in which quadrant the pathology and then we do ultrasound for all breast but specifically we focus in suspected lesion area .

Case 1 Directed Breast Ultrasound Irregular Solid Mass

Comparison Case 2: Patient Recalled From Screening

Simple Cyst

Mammographic signs of benign breast lesions Benign masses tend to be spherical with smooth borders & if they contain calcifications , it is coarser (macro) & more structured-punctate or round & are of similar density than that seen in carcinoma .

Mammographic signs of malignant breast lesions Malignant lesions tend to be of variable shape, irregular outline, calcification (the so called malignant microcalcification- calcification : different particle shape, density& the cluster shape is irregular or triangular pointing toward the nipple).

Warning Mammographic Signs of Breast Cancer Clustered calcifications , micro calcifications( not scattered )  suspect malignancy. Spiculated mass (spiky lump) . Assymetrical density of breast tissue. Skin thickening . Retraction (skin or nipple pulling inwards) . Focal distortion (something is pressing on tissue) . 46

Microcalcifications are an important sign of early breast cancer ,they are the dominant abnormality in 90% of in situ carcinomas. Technical advances in mammography equipment have lead to significant improvement in mammographic image quality and changed the ability to detect early breast carcinoma. 46

Routine craniocaudal mammogram spot-magnification mammogram Routine craniocaudal mammogram spot-magnification mammogram. clustered of microcalcifications Shows better details Histology revealed ductal carcinoma in situ 46

Case 3: Suspicious Calcifications

Cluster of calcification

Cluster of calcification

Cluster of calcification

CASE 4: Benign Calcifications

BENIGN CALCIFICATIONS 1-Skin or dermal calcifications. 2- Vascular calcifications. 3-Lucent-centered calcifications ( Fat necrosis ). 4- Egg-shell or rim calcifications( Fat necrosis or calcification in cyst wall). 5- Coarse or popcorn calcification( Fibroadenoma). 6-Large rod like calcifications or secretory calcifications. 7- Round or punctate calcification ( less than 0.5mm). 8-Milk of calcium ( in dependant part of the cyst ) 9-Suture calcification. 10-Dystrophic calcifications (Trauma, surgery and irradiation).

Dermal calcifications On the skin , it’s a benign calcification

Vascular calcifications Here the calcification surrounding the blood vessel

Lucent-Centered calcifications It’s a macro calcification and in the center there is lucency , seen in fat necrosis

Egg-shell or rim calcifications Seen in fat necrosis and in the wall of the cyst

Popcorn calcification Seen in fibroadenoma

Secretory calcification Large rod-like calcifications

Punctate calcification Round (less than 0.5 mm)

Milk of calcium seen in the dependant part of the cyst .

Suture calcification Previous history of surgery .

Dystrophic calcification ( truma, surgery, irradiation)

Fibroadenoma: well-circumscribed, oval-shaped mass with popcorn calcification

FEATURES OF MALIGNANCY 1- Speculated mass 2- Dense mass 3- Architectural distortion 4- Micro calcification 5- Asymmetry of breast tissue 6- Skin thickening 7- Pathological lymph nodes ( in the axilla mostly near the pectoralis major , to distingue if it benign or pathological: benign : rounded, well defined , central fatty hilum ( lucent in the center) pathological lymph node : dense and opaque , no fatty center

Speculated mass

Architectural distortion A focal area of breast tissue appears distorted with no definable central mass. -Causes: A- Malignancy : change over time. B- Benign lesions as in cases of prior breast injury or surgery or radial scar. -Benign lesions don’t change overtime.

Architectural distortion You can see here tethering breast tissue

ASYMMETRY OF BREAST TISSUE Greater volume or density of breast tissue in one breast than corresponding area in the contralateral breast.

ASYMMETRY OF BREAST TISSUE

Linear and branching micro calcification  suspect under lying malignancy

Cluster of calcifications The cause could be Ductal carcinoma in situ

Dense mass suspect malignancy CC

Dense mass

On the mammogram report Important BIRADS CODING CATEGORY 0 Incomplete ; needs further evaluation ( patient to refuse , to complete the study ) CATEGORY 1 Negative mammogram , normal fibro glandular tissue with no other finding. CATEGORY 2 Benign findings. ( fibro adenoma , benign lymph nodes , cyst ) CATEGORY 3 Probably benign finding- short interval follow up is suggested ( ex : patient with fibrocystic changes and nipple discharge mostly benign but .. You have to follow up to rule out malignancy )

CATEGORY 4 Suspicious abnormality- Biopsy should be considered ( hypo echoic cyst with irregular margins with shadowing it suspect malignancy so you do biopsy to confirm your diagnosis ) CATEGORY 5 Highly suggestive of malignancy –Appropriate action should be taken ( mass speculated with shadowing , cluster of classification , in examination the mass was hard , so its highly suggestive of malignancy ) CATEGORY 6 Proven malignancy

ACR/ACS Breast Cancer Screening Guidelines Annual mammography age 40 and older Reduction in mortality by 30-50% Earlier if mother or sister diagnosed with breast cancer (10 y. < age of relative’s diagnosis) Annual MRI for high risk per guidelines criteria Annual Clinical Breast Examination age 40 and older Q 3 years age 20-40 Self Breast Examination encouraged

Diagnostic Breast Imaging For symptomatic patients or those with an imaging finding Negative screening mammogram never replaces need for diagnostic mammogram Ultrasound essential in majority of (but not all) women for complete work up of palpable abnormality after mammography MRI can play an important role in specific clinical settings

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

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