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

2. Screening
Breast assessment in symptomatic FT clinics
Case studies

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

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

6. 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

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

8. ‘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

9. Symptomatic clinic / fast track clinic

10. Triple assessment
Multidisciplinary team approach
Concordance

11. Concordance of triple assesmentU B
Need for repeat biopsy or clinical core?

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

14. 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

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

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

17. Benign Calcifications

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

19. Architectural Distortion

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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)

36. 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

37. 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

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