Breast ImagingBreast Imaging

Olga HatsiopoulouOlga HatsiopoulouConsultant RadiologistConsultant Radiologist

Royal Hallamshire HospitalRoyal Hallamshire HospitalSheffield Breast Screening UnitSheffield Breast Screening Unit

Sheffield Teaching HospitalsSheffield Teaching Hospitals

ScreeningScreening

Breast assessment in symptomatic FT Breast assessment in symptomatic FT clinicsclinics

Case studiesCase studies

Five-Year Breast Cancer Suvival Rates According to the Size of the Tumor and Axillary Node Involvement

5 Year Survival, %

Tumor Size, cm 0 Positive

Nodes

1-3 Positive

Nodes

4 or More Positive

Nodes

< 0.5 99.2 95.3 59.0

0.5-0.9 98.3 94.0 54.2

1.0-1.9 95.8 86.6 67.2

2.0-2.9 92.3 83.4 63.4

3.0-3.9 86.2 79.0 56.9

4.0-4.9 84.6 69.8 52.6

?5.0 82.2 73.0 45.4

Breast Cancer: Why Screen?Breast Cancer: Why Screen?

Improved outcome by treatment Improved outcome by treatment during the asymptomatic periodduring the asymptomatic period

Significant impact on public healthSignificant impact on public health

Mortality ReductionMortality Reduction

50-69 y.o.: mortality reduction 16-35%50-69 y.o.: mortality reduction 16-35%

40-49 y.o.: mortality reduction 15-20%40-49 y.o.: mortality reduction 15-20%– Lower incidenceLower incidence– Rapidly growing tumorsRapidly growing tumors– Dense breastsDense breasts

Mortality ReductionMortality Reduction

Due to detection of cancers at smaller Due to detection of cancers at smaller size/earlier stagesize/earlier stage– Mammographically visible 3-5 years before Mammographically visible 3-5 years before

palpablepalpable

– Increased detection of DCISIncreased detection of DCIS

Early stage disease is curableEarly stage disease is curable

Diagnostic Accuracy of Screening Diagnostic Accuracy of Screening MammographyMammography

• Sensitivity in women > 50 y.o.Sensitivity in women > 50 y.o.• 98% fatty breast98% fatty breast• 84%84% dense breasts dense breasts

• SpecificitySpecificity• 82-98%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 clinicSymptomatic clinic / fast track clinic

Triple assessmentTriple assessment

Multidisciplinary team approachMultidisciplinary team approach

ConcordanceConcordance

Concordance of triple assesmentConcordance of triple assesment

P P M M U U B B

Need for repeat biopsy or clinical core?Need for repeat biopsy or clinical core?

Digital mammographyDigital mammography

Quicker to do mammo – almost instant Quicker to do mammo – almost instant output on monitoroutput on monitor

Better penetration of dense breastBetter penetration of dense breast

Digital manipulation of imageDigital manipulation of image

Digital mammographyDigital mammography

Proven to be better for younger/denser Proven to be better for younger/denser breastsbreasts

Almost eliminates the need for Almost eliminates the need for magnification views – can magnify digitally magnification views – can magnify digitally and still have full resolutionand still have full resolution

•Cranio-caudal projection (CC)•Medio-lateral oblique projection (MLO)

•Standard view mammography

CalcificationCalcification

Most are benign and can be dismissedMost are benign and can be dismissed

The goal is to identify new or increasing The goal is to identify new or increasing calcifications or those with suspicious calcifications or those with suspicious morphologymorphology

Benign CalcificationsBenign Calcifications

Malignant microcalcificationMalignant microcalcification

Linear, branching casts – comedoLinear, branching casts – comedo

Granular/ irregular – crushed stoneGranular/ irregular – crushed stone

Punctate - powderyPunctate - powdery

Architectural DistortionArchitectural Distortion

Core biopsyCore biopsy

All solid lumps and M3 MC get a biopsyAll solid lumps and M3 MC get a biopsy

Replaces fine needle aspiration in most Replaces fine needle aspiration in most casescases

14g spring-loaded needle gun14g spring-loaded needle gun

Well toleratedWell tolerated

Main complication is haemorrhageMain complication is haemorrhage

Core biopsy - histologyCore biopsy - histology

Can give grade of cancers and presence of Can give grade of cancers and presence of invasioninvasion

Can give definitive diagnosis of benign lesions - Can give definitive diagnosis of benign lesions - avoid surgeryavoid surgery

Ultrasound vs /stereo biopsyUltrasound vs /stereo biopsy

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

Prone biopsy tableProne biopsy table

Woman lies prone on elevated table with Woman lies prone on elevated table with breast dependent through a hope in the breast dependent through a hope in the tabletable

Biopsy is done from underneathBiopsy is done from underneath

Access is 360 degreesAccess is 360 degrees

VABVAB

Used with either ultrasound or stereo Used with either ultrasound or stereo guidanceguidance

Vacuum-assisted biopsy, single needle Vacuum-assisted biopsy, single needle insertion, larger sampleinsertion, larger sample

Allows better non-operative diagnosis, Allows better non-operative diagnosis, improved calc retrieval, more invasive improved calc retrieval, more invasive cancer detection in DCIScancer detection in DCIS

VAB biopsy VAB biopsy

11g, compared with 14g for core biopsy11g, compared with 14g for core biopsy

8g can be used to remove benign lumps8g can be used to remove benign lumps

Slightly greater risk of bleedingSlightly greater risk of bleeding

Well toleratedWell tolerated

Can insert clip to mark site in case lesion Can insert clip to mark site in case lesion is totally removedis totally removed

Why use such a large bore?Why use such a large bore?

A larger sample is more likely to obtain a A larger sample is more likely to obtain a definitive diagnosis:definitive diagnosis:– DCIS may be upgraded to invasive cancerDCIS may be upgraded to invasive cancer– ADH may be upgraded to DCISADH may be upgraded to DCIS– Small/difficult lesions are more likely to be Small/difficult lesions are more likely to be

adequately sampledadequately sampled– - Therapeutic excision of B3 lesions- Therapeutic excision of B3 lesions

Wire localisationWire localisation

Use U/S or stereo depending on how it is Use U/S or stereo depending on how it is best seenbest seen

Aim to get hook through the lesionAim to get hook through the lesion

Specimen x-ray after excision to confirm Specimen x-ray after excision to confirm lesion removelesion remove

LIMITATIONS OF LIMITATIONS OF MAMMOGRAPHYMAMMOGRAPHY

As many as 5 – 15% of breast cancers As many as 5 – 15% of breast cancers are not detected mammographicallyare not detected mammographically

A negative mammogram should not A negative mammogram should not deter work-up of a clinically suspicious deter work-up of a clinically suspicious abnormality abnormality

FALSE NEGATIVESFALSE NEGATIVES

CausesCauses–Occult on mammogram (lobular CA)Occult on mammogram (lobular CA)–Finding obscured by dense tissueFinding obscured by dense tissue–TechnicalTechnical–Error of interpretationError of interpretation

RISK OF MAMMOGRAPHYRISK OF MAMMOGRAPHY

Average glandular dose from a Average glandular dose from a screening mammogram is extremely screening mammogram is extremely lowlow

Comparable risks are:Comparable risks are:– Traveling Traveling 4000 miles by air4000 miles by air– Traveling Traveling 600 miles by car600 miles by car– 15 minutes of mountain climbing15 minutes of mountain climbing– Smoking 8 cigarettesSmoking 8 cigarettes

Breast MRIBreast MRI

Magnetic resonance imaging is used :Magnetic resonance imaging is used :

– For problem solvingFor problem solving

– For assessing the extent of lobular or extensive cancersFor assessing the extent of lobular or extensive cancers

– For screening high risk women - high risk family history For screening high risk women - high risk family history and women who have had mantle radiotherapy for and women who have had mantle radiotherapy for Hodgkins’ diseaseHodgkins’ disease

– Pre and post neoadjuvant chemotherapyPre and post neoadjuvant chemotherapy

– For women with implants, to assess integrityFor women with implants, to assess integrity

Detecting cancers on MRIDetecting cancers on MRI

Dynamic scan – bolus injection of Dynamic scan – bolus injection of Gadolinium and rapid sequence of imagesGadolinium and rapid sequence of images

Benign lesions can enhance Benign lesions can enhance

Need to create a graph showing pattern of Need to create a graph showing pattern of uptake over timeuptake over time

Cancers show rapid uptake and washoutCancers show rapid uptake and washout

The axillaThe axilla

UltrasoundUltrasound

– Level one nodes can be very low downLevel one nodes can be very low down– Level three nodes may be best seen from an Level three nodes may be best seen from an

anterior approach through the pectoralis anterior approach through the pectoralis major musclemajor muscle

Axillary node levelsAxillary node levels

Level one:Level one:– lateral to lat margin of pectoralis majorlateral to lat margin of pectoralis major

Level two:Level two:– under pectoralis minorunder pectoralis minor

Level three:Level three:– medial and superior to pectoralis minor, up to medial and superior to pectoralis minor, up to

clavicleclavicle

Why scan/ biopsy the axilla?Why scan/ biopsy the axilla?

A pre-operative diagnosis of lymph node A pre-operative diagnosis of lymph node metastases will prompt the surgeon to go metastases will prompt the surgeon to go straight to an axillary node CLEARANCEstraight to an axillary node CLEARANCE

A negative axilla on imaging will mean the A negative axilla on imaging will mean the woman has either:woman has either:– Sentinel node biopsySentinel node biopsy– Axillary sampling (four nodes)Axillary sampling (four nodes)

Advantages of axillary biopsyAdvantages of axillary biopsy

Avoids two operations in women with Avoids two operations in women with positive nodespositive nodes

Alternative is axillary sample at time of Alternative is axillary sample at time of WLE, then second operation for clearanceWLE, then second operation for clearance

What about PETWhat about PET

Indicated for the complex axilla/ brachial Indicated for the complex axilla/ brachial plexus problemplexus problem

May prove useful for looking for distant May prove useful for looking for distant mets but not accepted primary methodmets but not accepted primary method

Resolution and specificity not good Resolution and specificity not good enough to look for nodesenough to look for nodes

Importance of triple assesmentImportance of triple assesment

MDT approachMDT approach

ConcordanceConcordance

Challenges around breast screeningChallenges around breast screening

A well informed patientA well informed patient