Breast Imaging Olga Hatsiopoulou Consultant Radiologist Royal Hallamshire Hospital Sheffield Breast Screening Unit Sheffield Teaching Hospitals

Screening Breast assessment in symptomatic FT clinics Case studies

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

Mortality Reduction 50-69 y.o.: mortality reduction 16-35% Lower incidence Rapidly growing tumors Dense breasts

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

Diagnostic Accuracy of Screening Mammography Sensitivity in women > 50 y.o. 98% fatty breast 84% dense breasts Specificity 82-98%

‘On the positive side, screening confers a reduction in the risk of mortality of breast cancer because of early detection and treatment. On the negative side is the knowledge that she has perhaps a one per cent chance of having a cancer diagnosed and treated that would never have caused problems if she had not been screened.’ Professor Sir Michael Marmot, UCL Epidemiology & Public Health

Symptomatic clinic / fast track clinic

Triple assessment Multidisciplinary team approach Concordance

Concordance of triple assesment U B Need for repeat biopsy or clinical core?

Digital mammography Quicker to do mammo – almost instant output on monitor Better penetration of dense breast Digital manipulation of image

Digital mammography Proven to be better for younger/denser breasts Almost eliminates the need for magnification views – can magnify digitally and still have full resolution

Standard view mammography Cranio-caudal projection (CC) Medio-lateral oblique projection (MLO)

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

Benign Calcifications

Malignant microcalcification Linear, branching casts – comedo Granular/ irregular – crushed stone Punctate - powdery

Architectural Distortion

Core biopsy All solid lumps and M3 MC get a biopsy Replaces fine needle aspiration in most cases 14g spring-loaded needle gun Well tolerated Main complication is haemorrhage

Core biopsy - histology Can give grade of cancers and presence of invasion Can give definitive diagnosis of benign lesions - avoid surgery

Ultrasound vs /stereo biopsy Ultrasound is used for all lesions visible on ultrasound – quick and accurate Stereo biopsy is used for lesions not seen on ultrasound –mainly microcalcification (mostly screening women) Same principle as stereoscopic vision – two slightly different mammographic views allow calculation of depth

Prone biopsy table Woman lies prone on elevated table with breast dependent through a hope in the table Biopsy is done from underneath Access is 360 degrees

VAB Used with either ultrasound or stereo guidance Vacuum-assisted biopsy, single needle insertion, larger sample Allows better non-operative diagnosis, improved calc retrieval, more invasive cancer detection in DCIS

VAB biopsy 11g, compared with 14g for core biopsy 8g can be used to remove benign lumps Slightly greater risk of bleeding Well tolerated Can insert clip to mark site in case lesion is totally removed

Why use such a large bore? A larger sample is more likely to obtain a definitive diagnosis: DCIS may be upgraded to invasive cancer ADH may be upgraded to DCIS Small/difficult lesions are more likely to be adequately sampled - Therapeutic excision of B3 lesions

Wire localisation Use U/S or stereo depending on how it is best seen Aim to get hook through the lesion Specimen x-ray after excision to confirm lesion remove

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

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

Breast MRI Magnetic resonance imaging is used : For problem solving For assessing the extent of lobular or extensive cancers For screening high risk women - high risk family history and women who have had mantle radiotherapy for Hodgkins’ disease Pre and post neoadjuvant chemotherapy For women with implants, to assess integrity

Detecting cancers on MRI Dynamic scan – bolus injection of Gadolinium and rapid sequence of images Benign lesions can enhance Need to create a graph showing pattern of uptake over time Cancers show rapid uptake and washout

The axilla Ultrasound Level one nodes can be very low down Level three nodes may be best seen from an anterior approach through the pectoralis major muscle

Axillary node levels Level one: Level two: Level three: lateral to lat margin of pectoralis major Level two: under pectoralis minor Level three: medial and superior to pectoralis minor, up to clavicle

Why scan/ biopsy the axilla? A pre-operative diagnosis of lymph node metastases will prompt the surgeon to go straight to an axillary node CLEARANCE A negative axilla on imaging will mean the woman has either: Sentinel node biopsy Axillary sampling (four nodes)

Advantages of axillary biopsy Avoids two operations in women with positive nodes Alternative is axillary sample at time of WLE, then second operation for clearance

What about PET Indicated for the complex axilla/ brachial plexus problem May prove useful for looking for distant mets but not accepted primary method Resolution and specificity not good enough to look for nodes

Importance of triple assesment MDT approach Concordance Challenges around breast screening A well informed patient