1. CORE Case 15 Workshop Women’s Imaging: Malignancy and Screening
Cimmie Shahan, M.D.
Department of Radiology
WVU School of Medicine

2. Learning Objectives
Describe the current recommendations for screening mammography
Describe the approach to screening for patients who are high versus low risk for breast cancer
Distinguish between indications for “screening” and “diagnostic” mammography.

3. Learning Objectives
List common abnormalities that can be seen on mammograms
Describe how mammography is performed.
Summarize the BIRADS categories and their implications for patient management.

4. Learning Objectives
Describe the role of image guided core needle breast biopsies
Discuss how sentinel nodes studies are performed

5. Case 1
A 40 year old woman asks you when she should start screening mammography. What are some of the things you should consider?
1. National recommendations and local guidelines
2. Risk factors of this patient
What are the recommendations for screening mammography? When to begin? How often? When to stop?
(Yearly beginning at age 40 according to ACR, ACS, ACOG. When to stop screening is not as defined, but in general after the age of 75-80, patients need to be evaluated on an individual basis, i.e. if they have concurrent medical problems that likely will reduce life expectancy to less than five years; mammography is unlikely to be of benefit.)
Are you aware of the main controversy regarding screening mammography?
(In November 2009, the USPSTF changed their recommendations for screening mammogram. The panel recommended AGAINST screening mammograms for average risk women aged and >74 and AGAINST self or clinical breast exam. For women aged 50-74, they recommended screening mammogram every 2 years. Most clinicians, including radiologists, have strongly disagreed with these recommendations arguing that the USPSTF refused to look at substantial literature, which proved that there is a decrease in the mortality from breast cancer in women who undergo annual screening mammography, including women in the age group.). NOTE: USPSTF 2014 due out soon

6. What are some of the risk factors you might want to consider
What are some of the risk factors you might want to consider? What tools can you use for risk assessment?
Risks:
Family history of breast cancer, especially in 1st degree relative
Personal history of breast or ovarian ca
Known genetic mutations e.g. BRCA1 and 2, Li Fraumeni, Cowden, Peutz Jegher,
Radiation to chest as teen or in 20s
Known atypia on prior breast biopsy – e.g. ADH, ALH, LCIS
Early menarche, late menopause
White race
Lack of breast feeding
Alcohol drinking, obesity, increased breast density (mammographic)
HRT
Tools:
Various risk assessment tools e.g. Gail Model (on line These various models use some or all of these factors to identify which women are at increased risk of breast cancer. You may want to start screening earlier in these women.

7. You discuss pros and cons with this patient and you both agree that screening mammography should start What are the standard screening views obtained?
Say: her mother had breast cancer aged 51 so reasonable to start screening age 40.
A: craniocaudal (CC) and mediolateral oblique (MLO))

8. R L Topics to consider discussing:
Q: Which is MLO and which CC? A: Top are cc, right on the left
Q: How is the breast positioned for these views? A: CC – compressed from top to bottom. MLO – compressed along the long axis of the pectoralis.
Q: Why do we compress the breast A: Compression is used to decrease motion and radiation dose and spread out the breast tissue.
Q: See if they can identify the fat and glandular tissue, nipples and pectoralis

9. Positioning for mammogramCC
MLO
Q: Why do we take these two views? A: To maximize the amount of tissue that we see in at least one plane

10. What are the categories of breast density according to the BIRADS lexicon?
On every mammogram report we must describe the breast density according to the ACR.
A: Almost entirely fat 0-25%, scattered fibroglandular densities 25-50%, heterogeneously dense 50-75%, and extremely dense >75%
This patient is almost entirely fat.
Q: Why is breast density important? A: Cancers are more difficult to detect in women with dense breasts as both cancers and normal fibroglandular tissue are white on mammogram. There is a also a higher risk of developing breast cancer in denser breasts. Multiple states have now passed laws requiring that patients be informed of their breast density and thus consider alternative screening methods such as ultrasound and MRI (controversial)

11. Examples of breast densities
From left to right, almost entirely fat, scattered, heterogeneously dense, extremely dense.

12. If you feel a breast mass on a patient, or we are describing an imaging abnormality, what details are you going to write on your request?
Quadrants, or clock face (or both) and distance from the nipple.
Use this opportunity to reinforce that as clinicians they need to let us know this information as well as the size and consistency of the mass so we can correlate with our imaging findings

13. Site Side Size Characteristics of mass

14. Q: How do we describe the location of an abnormality seen in the breast? A: By quadrant of the breast or clock position.
The lateral portion of the breast is at the upper portion of the image on the CC view and the superior portion of the breast is at the upper portion of the image on the MLO view.

15. Clock face, imagine a clock with the patient facing you

16. Describe the location
Where would this lesion be located? (right breast 10 or 11 o’clock) 16

17. Describe the location
Where would this lesion be located? (left breast 7 or 8 o’clock) 17

18. Describe the location
Where would this lesion be located? (right breast 6 o’clock) 18

19. How do categorize mammograms to convey our level of concern about any lesions?
A: By law we need to include an ACR BIRADS category in our summary of a report. These will be on all patient’s reports
Q: Do they know what these categories are and what they mean (on next slide)?
Breast Imaging Reporting and Data System

20. BIRADS BIRADS category (details – discuss only if wish)
Incomplete - Needs additional imaging 1
Normal
~0 risk malignancy 2
Benign 3
Probably benign
less than or equal to 2% 4a
Low suspicion for malignancy
> 2% but less than or equal to 10% risk malignancy 4b
Moderate suspicion for malignancy
> 10% but less than or equal to 50% risk malignancy 4c
High suspicion for malignancy
> 50% but less than 95% risk malignancy 5
Highly suggestive of malignancy
95% or greater risk malignancy 6
Known malignancy
100% risk malignancy

21. What is the difference between screening and diagnostic mammography?
ASYMPTOMATIC, or symptoms such as waxing and waning breast pain, non-focal or bilateral diffuse breast pain, stable (for >2 years) palpable masses.
Standard views (CC, MLO unless need others to image all breast tissue)
Diagnostic:
Symptoms or signs – palp abnormalities, focal (‘one finger’) breast pain, nipple discharge or inversion
Call back from screening (cat 0 mammogram)
Short interval follow up from prior diagnostic mammogram (Cat 3)
Variable views +/- ultrasound depending on the concern

22. Your patient phones you 2 days after her screening mammogram, and tells you she has been ‘called back’. She is very anxious. What are you going to tell her?
Q: What is a ‘call back’ A: A call back is when the radiologist has identified an abnormality on the mammogram and the patient needs extra diagnostic views (mammogram was BIRADS 0)
Q: How often does a call back end up meaning the patient has cancer? A: About 5-10% of the time, so they need to reassure the patient
Q: How often does a breast biopsy from a screening examination end up being a cancer? A: About 25-30% of the time

23. Reported BIRADS categories
Screening mammography 0 (further work up required), 1, 2 Diagnostic mammography 1, 2, 3, 4, 5, 6
So they know what to expect on the reports:
Make sure that they understand that when we are reading screening mammography we should only assign 0 incomplete (additional imaging), 1 or 2 (normal, benign)
Diagnostic mammography is all about problem solving when the final category is assigned (should not be zero unless you are awaiting comparison with outside films)

24. What different types of abnormalities might we see on a mammogram?
Calcifications
Masses
Architectural distortion
Asymmetric densities (see in one view only)
Focal asymmetries (see in both views)
Global (diffuse) asymmetries

25. Architectural distortion Asymmetric densities Focal asymmetries
Calcifications
Masses
Architectural distortion
Asymmetric densities
see in one view only
Focal asymmetries
see in both views
There are other abnormalities such as skin thickening and lymphadenopathy that we see occasionally

26. What type of finding is this?
Mass (spiculated)
Note BB indicating this is a palpable mass

27. What type of finding is this?
Focal asymmetry – different from other side and see in two views, but does not have ‘mass like’ features
This may require further work up with additional views/US if new or seen on a baseline examination

28. What type of finding is this?
Global diffuse asymmetry on right (inflammatory breast cancer)
Note skin thickening inferiorly on right and axillary adenopathy

29. What type of finding is this?
Architectural distortion
This is one of the hardest things for radiologists to see! See if they can see it. Answer on next slide

30. What type of finding is this?
Architectural distortion
Show them how the tissue is ‘tethered’ and pulled in with sharp angles
This one was due to a surgical scar – the most common cause of arch distort. But cancers can definitely present like this and it is very suspicious in the absence of a history of surgery
This is one of the hardest things for radiologists to see!

31. Magnified view from prior study

32. What type of finding is this?
Asymmetric Density – only really see in one plane, turned out to be a cancer (NB, probably can see on the MLO in retrospect at about 11 O’clock)

33. What type of finding is this?
Multiple well defined masses, almost definitely cysts. When we see multiple especially bilateral well defined masses we can just call these cysts and call BIRADS 2.
Note how some of these are obscured by the dense tissue.

34. What type of finding is this?
Calcifications
This was ductal carcinoma in situ (DCIS)
Q: Do you know what kind of diagnostic technique we would used to evaluate concerning calcifications? A: Magnification views (shown here)

35. Benign or malignant? lipoma rmlo OPTIONAL SLIDES
Q: Are these masses benign or suspicious?
Q: What is their density/what do they contain? A: These are benign findings, BIRADS 2. They contain low density fat. Lipoma on left, oil cyst on right
Use this to explain that while often we cannot be definite by imaging, certain findings are characteristic for benign etiologies

36. Benign or malignant? OPTIONAL SLIDES
Q: Are these calcifications benign or suspicious? How would you describe them?
A: All are benign, BIRADS 2. Coarse popcorn calcifications (left) in a fibroadenoma , vascular calcifications (right),
Use this to explain that while often we cannot be definite by imaging, certain findings are characteristic for benign etiologies

37. Benign or malignant? OPTIONAL SLIDES
Q: What anatomy do you think these calcifications are growing in
Q: How would you describe them? A: Fine pleomorphic and fine linear branching
Q: Are these calcifications benign or suspicious? A: These calcification are the most suspicious types of calcifications
Use this to discuss how there are certain characteristics of calcifications that can make them much more suspicious

38. Ductal Carcinoma in Situ
Show how the calcifications in DCIS develop in the ducts, and that is why a linear/branching pattern concerns us

39. Calcifications Benign Malignant Shape Number Size Distribution
Other features
OPTIONAL SLIDES
It is not necessary for students to be able to read mammograms, but to have some idea of what we use to decide biopsies is helpful
See if they can come up with some answers here

40. Calcifications Benign Malignant Shape Number Size Distribution
Round
Popcorn
Linear, branched
Pleomorphic
Number
Few
Many
Size
Coarse
Fine
Distribution
Scattered
Ductal, grouped, segment
Other features
Lucent centered
OPTIONAL SLIDES
it is not necessary for students to be able to read mammograms, but to have some idea of what we use to decide biopsies is helpful
See if they can come up with some answers here

41. Case 2
32 year old woman with a family history of breast cancer, including her mother at age 42 and a two second-degree relatives. She is asking you if she is at “high risk” of breast cancer. What should you tell her and recommend?
Q: How and when should this patient begin screening? A: In patients with a first degree relative (FDR) who had a diagnosis of breast cancer, annual mammography beginning 10 years prior the age of diagnosis of first degree relative or age 40, whichever is earlier, but after age 25, is recommended. So this patient should begin annual mammography at age 32.
Q: What is the average risk of breast cancer A: Average risk patients have a lifetime risk of cancer of less than 15%.
Q: Who is considered high risk for breast cancer? A: High risk is >20-25% lifetime risk.
High risk includes women with:
known BRCA1 or BRCA2 gene mutation
FDR (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation (but have not had genetic testing themselves)
lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools
radiation therapy to the chest when they were between the ages of 10 and 30 years
Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have one of these syndromes in first-degree relatives. )
Q: What should you tell her and recommend? A: She is likely at increased risk of breast cancer. To determine if she is “high risk”, she should be referred to genetic counseling. Genetic counselors can determine the level of risk by using risk assessment models (such as the Gail model or others, eg. Tyrer Cuzick, BRCAPRO). They can also evaluate if the patient should undergo BRCA testing.

42. Case 2
You refer her to genetic counseling. Genetic testing is undertaken. The patient is found to be BRCA 2 positive. What screening modalities should be used in this BRCA 2 +/high risk patient?
Q: How do high risk get screened? A:Patients at high risk should be screened by annual mammogram and MRI (usually alternating every 6 months).)
Q: At what age do high risk patients begin screening? A: At age 30 for most of these patients. In patients with a history of chest radiation, begin at 25 or 10 years after completion of radiation, whichever occurs later. For women with BRCA mutations, age 25 should be considered.

43. Case 2:
Q: Do they see anything?
A: Her mammogram shows scattered fibroglandular densities and is negative, BI-RADS 1.

44. R L
Q: What imaging modality is this? A: MRI See if they can spot the breast cancer in the right breast (it was occult on the preceding mammogram).
Q: Is it important to given contrast (gadolinium) for MRI to detect breast cancer? A: Yes. Contrast is necessary to detect malignancy with breast MRI. Because malignancy in the breast almost always enhances, breast MRI is very sensitive.
Q: What are some problems with breast MRI ? A: specificity is generally lower and more variable. Many benign lesions in the breast that may enhance. MRI is a more expensive imaging modality as compared to ultrasound and mammography. MRI may be difficult in patients with claustrophobia and may not be able to be performed in patients with renal failure, implantable devices, or large body habitus
Q: What are other indications for breast MRI? A: High risk screening as discussed, evaluation for extent of disease and contralateral breast in patients with known cancer, evaluation for occult malignancy in patients with axillary LAD and unknown primary, evaluation of treatment response in the neoadjuvant chemotherapy population. Guidance of biopsy of a lesion only seen on MR. Assessment of breast implant rupture (no contrast)

45. Image of patient undergoing a breast MRI – patients are scanned prone, very large patients may not fit in scanner

46. What might we do now?
Call back for a directed ultrasound to see if we can see the mass to guide biopsy. If we can’t, then do an MRI guided biopsy

47. Is there any other type of screening that could be considered in this BRCA 2 positive patient?
 Q: What do we use for ovarian cancer screening in patients at high risk for ovarian cancer? A: Biannual CA-125 and transvaginal ultrasound
 Q: When should screening in these patients begin? (Age 30-35, for BRCA 2, age Therefore, this patient should consider screening beginning at least at age )
 Q: Is screening adequate for these patients throughout their lifetime? A: No. Since there are limitations of ovarian cancer screening, a salpingo-oopherectomy should strongly be considered upon conclusion of childbearing.
This patient is also at increased risk for ovarian cancer. Women with BRCA mutations have a 15-60% increased risk of ovarian cancer. Although there is no clear evidence that ovarian cancer screening will result in a decreased number of deaths from ovarian cancer, it is still recommended by National Comprehensive Cancer Network (NCCN) and American College of Obstetricians and Gynecologists (ACOG) that women with BRCA mutations and some other gene abnormalities consider screening until prophylactic salpingo-oopherectomy be performed.

48. Case 3 Current One year prior RCC RCC RMLO RMLO
62 year old woman, screening Mammogram
Q: Do you see anything new in the right breast on the current mammogram? A: Focal asymmetry in the right breast at 10:00 – see next slide
This is subtle and they may need help to see this
Current
One year prior

49. Case 3 Current One year prior RCC RCC RMLO RMLO
Q: What should we recommend next to further evaluate this finding? A: Diagnostic mammogram with spot compression views. This will help us to better characterize margins and help to determine if this could be just normal fibroglandular tissue. If a center has tomosynthesis, they may do that
Current
One year prior

50. Q: How is this spot compression diagnostic mammogram performed
Q: How is this spot compression diagnostic mammogram performed? A: Greater compression over the region of the abnormality in 2 projections. This pushes the overlying tissues apart allowing us to see the abnormality better. Sometimes a true view is also included or another type of view which may better see the abnormality depending on its position 
Q: Did this abnormality change in appearance? A:: It has become more defined and now appears to represent a mass with poorly defined margins.
Q: What imaging could we do to help further evaluate this mass? A: US

51. Q: Is this finding also suspicious on ultrasound
Q: Is this finding also suspicious on ultrasound? A: Yes, this is a solid irregular nonparallel mass with angular margins and posterior acoustic shadowing.
Point out to the students the use of RAD (Radial) and ARAD (antiradial) which is commonly used to describe how we position the transducer during breast ultrasound (shown on next slide)
Q: Now, what is your recommendation? A: US-guided biopsy
The pathology revealed invasive ductal carcinoma. Axillary lymph nodes appeared normal on US. This lesion measured 1.25cm on US.
Q: What are the two major surgical treatment options? A: Mastectomy and breast-conserving surgery (lumpectomy). No difference in survival rates for early stage breast cancer (this was stage 1)
This patient chose breast conservation surgery.
Q: What can the radiologists do next to localize the lesion for the surgeon? A: Needle localization procedure. In this case, US guidance can again be used. Explain how a small hooked wire is passed through a needle into the mass under imaging guidance to localize it for the surgeon.

52. RAD ARAD OPTIONAL SLIDE
Diagram explaining the RAD and ARAD terminology that they will see on US images. Note that this still produces images perpendicular to each other

53. RLM
RCC
Q: What is demonstrated here A: These are mammographic images with the wire in place localizing the lesion. The images are then marked for the surgeon.
 Q: What is the sentinel lymph node? A: The first draining lymph node.
Q: Does anyone know how we can find the sentinel node?
A: In patients without known or highly suspected axillary lymph node involvement, a sentinel node biopsy is performed at the time of mastectomy or breast conserving surgery. A radiologist injects a radioactive substance either intradermally and/or peritumorally or even in the periareolar location prior to surgery. During surgery the surgeon may also inject a blue dye around the tumor bed. The surgeon then uses a device that detects radioactivity to find the sentinel node or looks for lymph nodes that are stained with the blue dye. The sentinel node (s) are then checked for the presence of cancer cells by a pathologsit. If cancer is found, the surgeon may remove additional lymph nodes, either during the same procedure or during a follow-up surgical procedure.)

54. Q: What is demonstrated in the right image
Q: What is demonstrated in the right image? A: This is the specimen radiograph.
Q: Why do we do it? A: To confirm excision of the mass and that borders are adequate. It demonstrates the mass to be contained nearly in the center of the specimen.
Q: What is the metallic object in the mass A: that is the marker clip that we leave when we do a core needle biopsy under image quidance to mark where we biopsied.

55. Case 4
29 year old woman, palpable right breast lump What diagnostic imaging study should be performed first for a palpable abnormality in the breast? What if initial imaging is negative?
Q: According to the ACR appropriateness criteria, what diagnostic study should be ordered first for a palpable abnormality in a patient <30 years old? A: Ultrasound. If nothing is seen on ultrasound, it is at the discretion of the radiology/referring physician if a diagnostic mammogram is performed, but according to ACR appropriateness probably not appropriate (3 rating).
Q: Patient 40 or older? A: Diagnostic mammogram first – a BB should be placed on the skin over the palpable abnormality. If nothing is seen on mammogram, an ultrasound should be performed. If a mass or other density which is not definitely benign is seen, an ultrasound should also be performed.
Between tends to be institution dependent

56. US Images are at the site of the palpable abnormality.
Q: Is the finding suspicious on ultrasound? A:Yes, this is a solid hypoechoic mass with foci of internal echogenicity and poorly defined margins. Internal doppler flow is present.
 Q: What are reasonable choices for the next step? US-guided biopsy or diagnostic mammogram for further evaluation given the suspected microcalcifications in the mass

57. In this case a diagnostic mammogram was performed.
Q: Does it confirm the presence of calcifications? A: Yes, pleomorphic calcifications are present
Q: What are options for biopsy? A: Stereotactic and US-guided are options for core biopsy. Surgical excisional biopsy is another consideration but less invasive biopsy techniques are now favored as they result in fewer positive margins and repeat surgeries. It also allows presurgical planning by MRI, and patients have the opportunity to discuss other surgical options such as mastectomy and reconstruction

58. What are our options for image guided breast biopsies
What are our options for image guided breast biopsies? Why do we pick one over another?
1. Ultrasound guided
2. Stereotactic
3. MRI guided
4. (Needle localized surgical excision)
We usually pick the fastest, cheapest method that provides the least patient discomfort that we can see the abnormality on adequately to biopsy – generally in the order listed. If we can only see the abnormality on MRI, we will have to use MRI guidance to do the biopsy

59. OPTIONAL SLIDE
Q: Do you know what type of biopsy these images are from? A: Stereotactic breast biopsy
Q: Can you explain in general how a stereotactic biopsy is performed? (
A: stereotactic paired images at +15 and -15 degrees are obtained with the breast in compression. Based on these images, the computer calculates coordinates which are used to place the biopsy device properly in the breast. Vacuum assisted needle devices are used to take several tissue samples. Samples can be imaged to confirm the presence of the suspicious calcifications in the specimen. Clips are placed at the site of biopsy)
Generally, patients are lying on their bellies for this procedure
The pathology was ductal carcinoma in situ.

60. Tomosynthesis
Have you ever heard of tomosynthesis? How does it differ from regular mammography? What are the advantages?
OPTIONAL – but as now much more widely used, consider including it to make sure that students are aware of the modality
A: Tomosynthesis uses a method where a series of mammograms are taken as an xray emitter swings in an arc over the breast. The software reconstructs this into a series of thin slices through the breast in a similar way to CT (sometimes called a “3D mammogram”)
A: Decreased callbacks through identification of ‘superimposition’. Improved cancer detection.
It can be used for both screening and diagnostic uses.

61. Tomosynthesis Acquisition
X-ray tube
Compression plate
Breast slices
Courtesy of A. Smith, Hologic Inc.
OPTIONAL SLIDE
Digital detector
Reconstructed
planes

62. L CC focal comp L CC tomo frame
Demonstration of how the tomo images on the right show the cancer much better