Basic Mammography

8/6/2019 Basic Mammography

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BasicBasic

MammographyMammography

DARUNEE BUNJUNWETWAT MD.


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Breast imaging

MammographyUltrasonography

MRIScintimammography


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MammographyFood and Drug Administration ( FDA )

June 2, 1993

Most effective for early breast cancer

detection

Screening mammography

Screening interval


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Diagnostic mammography


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Women > 40 years

Yearly, annual check up

Early cancer detection


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Early stage Cure

Small size < 1 cm

Free of metastases

Non-palpable


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High risks

Early menarch

Late menopause

Nulliparity

Late age at full term pregnancy (> 30 yrs )

Biopsy proof atypical epithelial

proliferationBiopsy proof lobular carcinoma in situ

(Kopans DB. Breast imaging Lippincott-Raven p45)


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High risksGenetic ( BRCA 1, BRCA 2 )

Environmental

Gene-environmental interaction

Affected first degree relative( mother, sister, daughter )

Previous history of cancer

( breast , ovary )Ronbidoux et al, AJR 166(1): 29-31, 1996

Foulkes et al, Clinical and intensive Medicine 18(6):

473-483, 1995


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American cancer society ( ACS )

National cancer institution ( NCI )

Screening mammography 40-80 yrs

High risks 35 yrs


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Mammography

Technique : standard two views

( MLO , CC views)

: additional views

( spot compression,magnification )


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Standard views

1. Mediolateral oblique ( MLO )

2. Craniocaudal ( CC )


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Supplement viewsSpot compression

Magnification

True lateral

Exaggerated medial or lateral CCTangential

RolledCleavage ( buttock )

Axillary views


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Technique

Pulling

Compression

AngleBreath holding


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MLO view

Length and contour of pectoralismuscle

Nipple Inferior mammary angle

Pitfall Inner quadrant


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CC view

Visualized pectoralis muscle 30-40 %

Retromammary fat

Pectoralis-Nipple line ( PNL )

Stress on inner aspect


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Mammography RisksLow dose radiation ( 2mGy per view )

Compression effect

Uncertainty in diagnosis of CA in situ

( Napol et al; Journal of National CancerInstitute Monograph (22):11-3, 1997 )


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Anatomy of breastAnatomy of breast1. Mammary gland

2. Ducts

3. Collagenous connective tissue

4. Fatty tissue

5. Cooper ligament

6. Vessels and lymphatic


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Breast evolution and involution Individual

Age

Hormonal

Menstrual cyclesPregnancy

LactationMenopausal


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Menarchal development

15 yrs 25 yrs

Lobular structure, duct system

( hypoplasia, inverted nipple, juvenilehypertrophy, fibroadenoma )


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Cyclical change

Premenstrual phase ( endocrinestimulation )

Epithelial and stromal activity,

regressionBreast enlarge, patchy density

( fibrosis, adenosis, lymphoidproliferation, mastalgia, nodularity )


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Pregnancy, Lactation

Pronounced glandular activity

Superimposed cyclical change

Patchy


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Post Lactation

Some areas of regression

Fibrosis


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Involution30yrs - 40yrs till menopause

Lobular regression

( involution of epithelium )

Replacement of fibrous tissue in

interlobular regression sclerosis,

microcyst formation


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Breast patterns

Fatty breast

Ductal

Dense breast


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Wolfe Classification

Ducts, lobules, fibrosis

Linear and nodular opacities


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N1 = Parenchymal chiefly fat

P1 = Duct pattern in anterior portion

< of breast volume

P2 = Duct pattern > of breast volume

DY = Confluence densities or dysplasia

( AJR 126: 1130-1139, 1976 )


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Histologic appearance of P1, P2

connective tissue hyperplasia

surrounding duct

periductal collagenosis


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Histologic appearance of DY

severe mammary dysplasia

adenosis, microcyst formation


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Wolfes study

Parenchymal patterns and cancerrisk

DY + P2 > P1 + N1 6 times


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Thai women 444 cases

Negative mammograms

Technique MLO, CC views

DY 60 6% 40 50


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DY 60.6%

P2 46.8%

30.7%

P1 47.8%

N1 50%

40 50 yrs

40 50 yrs

50 60 yrs

50 60 yrs

60 70 yrs


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DY + P2 80% of Thai women


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Breast parenchymal density

ACR BIRADS 4 level systems

Fatty

Scattered fibroglandular densities

Heterogeneously dense

Extremely dense


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ASSESSMENT CATEGORIES

Mammographic assessment is

incompleteCategory 0

Need Additional Imaging Evaluation and/or Prior

Mammograms For Comparison


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Mammographic Assessment IsCompleteFinal CategoriesCategory 1

NegativeCategory 2

Benign Finding(s)

Category 3 Probably Benign FindingInitial Short-

Interval Follow-Up Suggested


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Category 4

Suspicious Abnormality

Biopsy Should BeConsidered

Category 5 Highly Suggestive of MalignancyAppropriate

Action Should Be Taken (Almost certainly malignant.)


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Category 0 almost always used in a screening situation.

additional imaging evaluation may include,but is not limited to the use of spot

compression, magnification, special

mammographic views and ultrasound. should only be used for old film comparison

when such comparison is required to make a

final assessment.


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Category 1 The breasts are symmetric and no masses,

architectural distortion or suspiciouscalcifications are present.


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Category 2

Involuting, calcified fibroadenomas, multiple

secretory calcifications, fat-containing lesionssuch as oil cysts, lipomas, galactoceles and

mixed-density hamartomas all have

characteristically benign appearances

Intramammary lymph nodes, vascular

calcifications, implants or architectural

distortion clearly related to prior surgery whilestill concluding that there is no

mammographic evidence of malignancy


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Both Category 1 and Category 2

assessments indicate that there is nomammographic evidence of malignancy.

The difference is that Category 2 should be

used when describing one or more specificbenign mammographic findings in the report,whereas Category 1 should be used when no

such findings are described.


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Category 3 Less than a 2% risk of malignancy

Three specific findings are described asbeing probably benign

noncalcified circumscribed solid mass

focal asymmetry cluster of round [punctate] calcifications

exclude palpable lesions


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an initial short-term follow-up (6 months)

examination (usually unilateral mammogram)followed by additional examinations (bilateral

F/U in another 6 months and then bilateral

12-month F/U) until longer-term (2 years orlonger) stability is demonstrated may be

changed to Category 2

occasional biopsy when patient wishes orclinical concerns


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Category 4 For findings that do not have the classic

appearance of malignancy but have a widerange of probability of malignancy that is

greater than those in Category 3.

Most recommendations of breastinterventional procedures will be placedwithin this category.


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Subdivided to account for the vast range of

lesions subjected to interventional proceduresand corresponding broad range of risk of

malignancy

Category 4A, 4B and 4C


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Category 4A

need intervention but with a low suspicion formalignancy

palpable, partially circumscribed solid mass withultrasound features suggestive of a fibroadenoma,

a palpable complicated cyst or probable abscess


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Category 4B Intermediate suspicion of malignancy

warrant close radiologic and pathologic

correlation

partially circumscribed, partially indistinctlymarginated mass yielding fibroadenoma or

fat necrosis is acceptable, but a result of

papilloma might warrant excisional biopsy


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Category 4C

Moderate concern, but not classic(as in Category5) for malignancy

ill-defined, irregular solid mass or new cluster offine pleomorphic calcifications

malignant result in this category is expected


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Category 5 High probability (> 95%) of being cancer

Example, spiculated, irregular high-density mass,

segmental or linear arrangement of fine linear

calcifications or irregular spiculated mass with associated

pleomorphic calcifications


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Category 6

For lesions identified on the imaging study

with biopsy proof of malignancy prior todefinitive therapies

No associated intervention required to

confirm malignancy

Appropriated for second opinions or formonitoring of responses to neoadjuvant

chemotherapy prior to surgical excision


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Not appropriate following excision of a

malignancy (lumpectomy )

A major rationale for adding Category 6 is

that examinations meriting this assessmentshould be excluded from auditing

If include inappropriately indicate inflated cancer

detection rates, positive predictive values, and otheroutcomes parameters

Fibrocystic change


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y g


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Popcorn calcifications

Popcorn calcifications


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Hamartoma

Hamartoma


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Lipoma

Galactocele

Oil cyst (fat necrosis)


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CaseCase 1


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guide


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Case 2


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Fibroadenosis

Case 2


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Case 2


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Case 2


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Thank you

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Basic Mammography