Basic Course For Medical College Student Breast Imaging Basic Course For Medical College Student WANG Deng-bin MD,Ph.D Dept. of Radiology,RuiJin Hospital WANG Deng-bin MD,Ph.D Dept. of Radiology,RuiJin Hospital

Introduction “Breast cancer is one of the best studied human tumors, but it remains poorly understood” “ As in all medical endeavors, the practitioner should, whenever possible, use the results of scientific studies to guide clinical decision”

And the imaging modalities implemented in clinical practice for breast care must be served as the tools for detection and characterization of breast lesions. As we expect, they are very important for diagnosis and treatment.

Imaging Modalities

1.5T MRI 1.5T MRI GE signa gemsow GE signa gemsow 0.5T MRI GE signa Sys#MRS Shanghai 2 nd Medical University Rui Jin Hospital

X-ray Examination Mammograpy  X-ray radiography (molybdenum X rays, rhodium X rays):MLO,CC,etc.  Galactography --demonstrates the ducts and ductule or their abnormalities.  X-ray radiography (molybdenum X rays, rhodium X rays):MLO,CC,etc.  Galactography --demonstrates the ducts and ductule or their abnormalities.

galactography

USG  Ultrasonography (ultrasound) B-mode US Doppler US  Ultrasonography (ultrasound) B-mode US Doppler US

CT  Computed tomography plain scan, enhanced scan (iodine)  Computed tomography plain scan, enhanced scan (iodine)

MRI  Magnetic Resonance Imaging high resolution for soft tissue different tissue, different signal enhanced scan  Magnetic Resonance Imaging high resolution for soft tissue different tissue, different signal enhanced scan

The others  Infrared thermal imaging  Computer diaphanography imaging,etc.  Infrared thermal imaging  Computer diaphanography imaging,etc.

Imaging-Guided Percutaneous Biopsy supply specimens for pathologic examination  Fine needle aspiration biopsy (FNAB)  Needle core biopsy (NCB)  Fine needle aspiration biopsy (FNAB)  Needle core biopsy (NCB)

Interventional Therapy  Laser  Radiofrequency  Embolization  and so on  Laser  Radiofrequency  Embolization  and so on

Accessory Breast Tissue  The most common site is axilla

Basic Imaging Signs of Breast Lesion  Mass/Lump  Calcification  Thickening and retraction of regional skin  Retraction of nipple  Enlargement or abnormality of blood vessels  Lymph nodes  Enhanced manifestations  Mass/Lump  Calcification  Thickening and retraction of regional skin  Retraction of nipple  Enlargement or abnormality of blood vessels  Lymph nodes  Enhanced manifestations

Mass/Lump shape: round, oval, regular/irregular margin: clear or ambiguous, spiculation or smooth density or signal intensity: high/low/intermediate with or without calcification site: upper-outer quadrant breast, upper-inner quadrant breast, lower outer quadrant breast, lower-inner quadrant breast, nipple, central portion breast, axillary tail breast. Number: solitary or multiple shape: round, oval, regular/irregular margin: clear or ambiguous, spiculation or smooth density or signal intensity: high/low/intermediate with or without calcification site: upper-outer quadrant breast, upper-inner quadrant breast, lower outer quadrant breast, lower-inner quadrant breast, nipple, central portion breast, axillary tail breast. Number: solitary or multiple

Calcification Size: large or micro Shape: ring-like, nodular or salt-like, branching Distribution: scattered or clustered with or without mass benign / malignant Size: large or micro Shape: ring-like, nodular or salt-like, branching Distribution: scattered or clustered with or without mass benign / malignant

Thickening and Retraction of Regional Skin  Frequently found in malignant tumors  Sometimes due to postsurgical scars.  Frequently found in malignant tumors  Sometimes due to postsurgical scars.

Retraction of Nipple  Congenital-dysplasia  Acquired-malignant tumor  Congenital-dysplasia  Acquired-malignant tumor

Enlargement or Abnormality of Blood Vessel  Mostly in malignant tumor due to increase of blood supply

Enlargement of Lymph Nodes  Axillary or intramammary lymph nodes

Administration of Contrast Agents for Breast Lesions  Implication of the lesion’s hemodynamics washout type--malignant linear--benign plateau--malignant/benign  Implication of the lesion’s hemodynamics washout type--malignant linear--benign plateau--malignant/benign

Common Diseases in Breast  Fibroadenoma  Cyst  Lobular hyperplasia  Cancer  Fibroadenoma  Cyst  Lobular hyperplasia  Cancer

Fibroadenoma overview Frequency: most common tumor of breast (benign) Age: below 30 yrs Distribution: unilateral or bilateral Source tissue: connective tissue and glandular tissue Site: upper-outer quadrant Size: < 5cm Surface: smooth, movable Frequency: most common tumor of breast (benign) Age: below 30 yrs Distribution: unilateral or bilateral Source tissue: connective tissue and glandular tissue Site: upper-outer quadrant Size: < 5cm Surface: smooth, movable

Imaging Findings of Fibroadenoma  X-ray  CT  MRI  X-ray  CT  MRI

X-ray Findings  Round, lobular or oval mass or nodule,smooth nodule in high density with thin ring/ halo in low density  Compression of surrounding tissue  Large calcification:always dominated at the center of tumor  Round, lobular or oval mass or nodule,smooth nodule in high density with thin ring/ halo in low density  Compression of surrounding tissue  Large calcification:always dominated at the center of tumor

CT Findings  Round smooth mass/nodule  Value of CT similar to normal glandular tissue  Calcification  Intermediate enhancement, linear type or plateau,relatively long duration of enhancement  Round smooth mass/nodule  Value of CT similar to normal glandular tissue  Calcification  Intermediate enhancement, linear type or plateau,relatively long duration of enhancement

Breast Cancer overview  most frequent malignancy in women 1% in adult women in China 34.4/100 thousand in /100 thousand in /100 thousand in /100 thousand in women of Shanghai in 2001 over 100/100 thousand in women in Europe and USA  most frequent malignancy in women 1% in adult women in China 34.4/100 thousand in /100 thousand in /100 thousand in /100 thousand in women of Shanghai in 2001 over 100/100 thousand in women in Europe and USA

Breast Cancer overview Age: 40-60yrs, in China 1/5 are <35yrs Gender: female (male) Clinical mass: unmovable mass, skin,orange-peel-like,retraction aching retraction/discharge of nipple enlargement of blood vessels stiffness of breast lymph nodes Age: 40-60yrs, in China 1/5 are <35yrs Gender: female (male) Clinical mass: unmovable mass, skin,orange-peel-like,retraction aching retraction/discharge of nipple enlargement of blood vessels stiffness of breast lymph nodes

Breast Cancer overview  Pathology Invasive ductal carcinoma65-80% Intraductal carcinoma 15% Lobular carcinoma(invasive/in situ) 5% Special types 10%  Pathology Invasive ductal carcinoma65-80% Intraductal carcinoma 15% Lobular carcinoma(invasive/in situ) 5% Special types 10%

X-ray Findings of Breast Cancer(1)  Irregular/regular mass  Ambiguous border  Spiculations  Heterogeneous density, mostly higher than the Surrounding tissue  Site: over 50% at upper-outer quadrant  Irregular/regular mass  Ambiguous border  Spiculations  Heterogeneous density, mostly higher than the Surrounding tissue  Site: over 50% at upper-outer quadrant

X-ray findings of breast cancer(2)  Calcification: clustered salt-like microcalcification in 1/3 cases inside/outside the mass, sometimes only the microcalcifications observed  Retraction of nipple  Thickening of skin  Abnormal blood vessel  Large patchy region in high density  Calcification: clustered salt-like microcalcification in 1/3 cases inside/outside the mass, sometimes only the microcalcifications observed  Retraction of nipple  Thickening of skin  Abnormal blood vessel  Large patchy region in high density

CT Findings of Breast Cancer(1)  Mass: irregular/ill-shaped, coarse margin, spiculation, CT value: 25-56HU, higher than the normal breast, necrosis at the center of the large mass(mostly >= 5cm)  Skin, nipple  Infiltration into the pectoralis major muscle  Mass: irregular/ill-shaped, coarse margin, spiculation, CT value: 25-56HU, higher than the normal breast, necrosis at the center of the large mass(mostly >= 5cm)  Skin, nipple  Infiltration into the pectoralis major muscle

CT Findings of Breast Cancer(2)  Occupying of retromammary space  Enlargement of lymph nodes, axillary/retromammary  Administration of contrast agents quick enhancement (wash in) at early phase the peak of enhancement occur within 50s ~1min quick washout time-signal intensity curve——washout type  Occupying of retromammary space  Enlargement of lymph nodes, axillary/retromammary  Administration of contrast agents quick enhancement (wash in) at early phase the peak of enhancement occur within 50s ~1min quick washout time-signal intensity curve——washout type

MRI Findings of Breast Cancer  Signal intensity:T1WI SE,low;T2WI FSE,low,intermediate,inhomogeneous;STIR, intermediate  Spiculation: irregular mass (lobular)  Enhancement: time-signal intensity curve  Signal intensity:T1WI SE,low;T2WI FSE,low,intermediate,inhomogeneous;STIR, intermediate  Spiculation: irregular mass (lobular)  Enhancement: time-signal intensity curve

Comparison of Different Imaging Modalities for Detection and Characterization of Breast Cancer  Molybdenum X-ray radiography: most important,widest used,most useful—not very sensitive to the small lesion at very early stage in dense breast;but digital mammography can solve the problem to great extent  Molybdenum X-ray radiography: most important,widest used,most useful—not very sensitive to the small lesion at very early stage in dense breast;but digital mammography can solve the problem to great extent

USG  Cystic or solid  Low spatial resolution  Limited ability to Differentiate benign/malignant  Cystic or solid  Low spatial resolution  Limited ability to Differentiate benign/malignant

CT  Wide coverage for viewing,sensitive to cystic change,hemorrhage and calcification  Very useful for detection and characterization of masses,especially in the enhanced scan, but can’t definitely view the microcalcification  Much more radiation,expensive  Wide coverage for viewing,sensitive to cystic change,hemorrhage and calcification  Very useful for detection and characterization of masses,especially in the enhanced scan, but can’t definitely view the microcalcification  Much more radiation,expensive

MRI  High soft resolution  Better differentiation for benign/malignant  Wider coverage  Without radiation  High cost  Not sensitive to calcification  High soft resolution  Better differentiation for benign/malignant  Wider coverage  Without radiation  High cost  Not sensitive to calcification

CT C - CT C + MR C +

Combination of Varying Imaging Modalities  Acquire the richest information  Appropriateness in application  Cost-effectiveness  Best diagnosis, timely correct therapy, better health  Acquire the richest information  Appropriateness in application  Cost-effectiveness  Best diagnosis, timely correct therapy, better health

 To the women of the world, may breast cancer soon be eliminated as a source of dread and death  To breast cancer researchers and breast health caregivers, may our efforts soon be unnecessary  To the women of the world, may breast cancer soon be eliminated as a source of dread and death  To breast cancer researchers and breast health caregivers, may our efforts soon be unnecessary

Thank You