Modern Imaging in Breast Cancer

Dr Linda HackingConsultant Radiologist

October is Breast Cancer Awareness Month

• Breast cancer is commonest cancer in UK (excluding non-melanoma skin cancer)

• 46,000 new cases per year• 300 men, remainder women• 80% over 50 years of age• 1 in 9 women will get it in their lifetime

Bad news/Good news

• Incidence has increased by 50% in last 25years• 12,000 women and 70 men died from breast

cancer in 2008• 1,300 deaths in women under 50• More than half deaths are in women over 70

Bad news/Good news

• Since 1980s breast cancer death rates have fallen by one third

• Breast cancer is no longer the commonest cause of cancer death in women

• More than 8 out of 10 women survive beyond 5 years (5 out of 10 in 1970s)

• Now twice as likely to survive 10 years as 40 years ago.• 2 out of 3 women survive beyond 20 years• Breast cancer death rates falling faster in UK than rest

of Europe

Reasons for improvements in outcomes

• Screening• Improved treatments (Tamoxifen etc)• Improved cancer services including imaging

Why are these improvements happening

• Breast screening?? (also increased diagnosis rate)

• Improved treatments (tamoxifen etc.)• Overall improvements in care (including

imaging)

Breast Screening

• NHS Breast Screening Programme (NHSBSP)• Began 1988-90• Not Blackpool Victoria.• Nearest centre Lancaster (vans, WGD)• Invited for Mammograms from age 50-69• Extended from 47-73 years from 2012 (target)• Past upper age limit, option to arrange

mammogram.

Breast Screening

• Will cause increase in incidence of cancer• Early cancers and pre-cancer (DCIS) are found

that would never have led to a problem

For Breast Screening

• One woman will be over-treated for every two lives saved

• 1000 lives a year saved• Impact on population vs individual woman’s

life.

Against breast screening

• 10% of cancers are over-diagnosis and therefore over –treatment

• It is impossible to estimate lives saved because of all other factors

• Impact on population vs impact on individual woman’s life

Today we are talking about diagnosis

The Symptomatic Breast Clinic

• Lump or thickening• Change in size or shape• Redness or rash in skin or nipple• Indrawing of nipple• Skin puckering or dimpling• Lump in armpit

Referral to Breast Clinic

• May simply need to see senior clinician- no further –advice, no further investigations.

• Triple assessment/Double assessment• See Senior Clinician (1)• Imaging (2)• Biopsy or needle test (FNA) (3)

Modern Imaging and Biopsy

• Tests to be done at first clinic appointment for most patients

• Most patients will have a benign diagnosis• Less than 1 in 10 patients attending our clinic will

have a malignant diagnosis• 9 out of 10 will be benign • In new clinic, results for patients seen Monday,

Tuesday available for Friday• Wednesday, within a week

Modern Imaging and Biopsy

• Quick accurate diagnosis for the majority of patients who will have a benign diagnosis

• As much information as possible about what we are dealing with in the minority if patients who have a malignant diagnosis

• Treatment can then be tailored to the individual patient

Mammography

• Symptomatic patients• Women >35 years of age• Uses x-radiation• Invented in 1960s, modern type of machine 1969• Still not in universal use 1986 (when I started in

radiology)• First unit Blackpool 1990 (Fylde Coast incl.NHS)• Blackpool Victoria Mammography unit 1999.• October 2010 Full Field Digital mammography

Mammography

• Problems • X-radiation• Dense breasts• Young women • Men• Implants• No imaging 100% accurate

Field Digital Mammography

• Better on all counts• Dense breast• Younger women• Less radiation

Ultrasound

• First imaging <35, and men• To clarify lumps and cysts on mammogram• To do image guided biopsy• To look at axilla (armpit)

Ultrasound

Cyst

Fibroadenoma

Ultrasound guided biopsy

Ultrasound guided biopsy

• Needle guided into abnormality under direct vision

• Can be needle test (FNA)• Or Core biopsy• Uses local anaesthetic• Takes 5-10 minutes• “a bit like getting ears pierced”• Complications- bruising, pain

Ultrasound guided biopsy

• Quick very accurate results• A patient specific individual plan if surgery

required• Tumour grade if malignant• Hormone receptor status (Tamoxifen, herceptin)• Size and extent of mass(es)• Lymphnodes• Test done Tuesday, results Friday

Core Biopsy Needle

Ultrasound guided biopsy

Mammographic stereotactic biopsy

• Mass seen on mammogram, not on ultrasound• Micro-calcification “chalky bits”- can be benign,

can be malignant or pre-malignant (DCIS)• No lump felt• Standard core biopsy• Vacuum assisted core biopsy• Special devices

Mammographic stereotactic biopsy

• Previously may have needed general anaesthetic surgery to remove abnormality

• Now outpatient procedure under local anaesthetic

• Most turn out to be benign

Vacuum assisted biopsy

Vacora vs 14G biopsy

Sample can be x-rayed

Breast MR (magnetic resonance)

Breast MR

• Also major investment in breast coils and software for new MR scanner

• Increased comfort• Ease of interpretation (software)

Breast MR

• Recently in press• In UK not used in every case• Lobular carcinoma• Multifocal carcinoma• Problem solving when imaging/clinical/pathology

do not match• Doubts about mastectomy/ local excision• Question of recurrence • Implants

Breast MRI

• Adds to planning of surgery

So far

We have been talking about diagnosisImaging also helps during surgery

Localisation of mass not felt

• Marker with ultrasound• Wire with stereotactic mammography• Mass can be x-rayed while patient still

anaesthetised

Excised specimen

Also during surgery-Sentinel Lymph Node Biopsy (SLNB)

SNLB• Small amount radioactivity injected into breast • On morning before afternoon surgery• Or afternoon before morning surgery• Also blue dye in theatre• Goes to first lymph node• Surgeon uses probe in theatre• No drain, much reduced complication rate

compared with Node Clearance• Seroma, lymphoedema, pain, numbness• Overnight stay vs several day stay

SLNB

• A small percentage will require further surgery once node examined in lab

• Nodes examined with ultrasound and FNA prior to surgery

• Not suitable for everyone

Surgical probe

The Future

• Tomosynthesis• On table sentinel node diagnosis• Answers about breast screening

http://www.youtube.com/watch?v=P5n3Avqqo2c

To Summarise

• Blackpool Victoria has opened a brand new breast clinic

• We have the latest technology available for the best possible care for our patients

• The new clinic pathway for rapid access and diagnosis will benefit all of our patients

• Most patients will have a benign diagnosis delivered quickly

• For the few patients who unfortunately have a malignant diagnosis

• They will be treated quickly, with all of the latest technologies available

• We should be able to upgrade for the future

The outlook is good

Thanks to the team!