Breast Imaging - Anatomy and Techniques  · PPT file · Web view2013-10-21 · Breast Imaging Olga…

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  • Breast Imaging

    Olga Hatsiopoulou

    Consultant Radiologist

    Royal Hallamshire Hospital

    Sheffield Breast Screening Unit

    Sheffield Teaching Hospitals

  • ScreeningBreast assessment in symptomatic FT clinicsCase 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?

    Improved outcome by treatment during the asymptomatic periodSignificant impact on public health

  • Mortality Reduction

    50-69 y.o.: mortality reduction 16-35%40-49 y.o.: mortality reduction 15-20%

    Lower incidence

    Rapidly growing tumors

    Dense breasts

  • Mortality Reduction

    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

  • Diagnostic Accuracy of Screening Mammography

    Sensitivity in women > 50 y.o.

    98% fatty breast

    84% dense breasts

    Specificity

    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 clinic

  • Triple assessment

    Multidisciplinary team approach

    Concordance

  • Concordance of triple assesment

    P

    M

    U

    B

    Need for repeat biopsy or clinical core?

  • Digital mammography

    Quicker to do mammo almost instant output on monitor

    Better penetration of dense breast

    Digital manipulation of image

  • 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

  • Cranio-caudal projection (CC)

    Medio-lateral oblique projection (MLO)

    Standard view mammography

  • Calcification

    Most are benign and can be dismissedThe goal is to identify new or increasing calcifications or those with suspicious morphology

  • Benign Calcifications

  • Malignant microcalcification

    Linear, branching casts comedo

    Granular/ irregular crushed stone

    Punctate - powdery

  • Architectural Distortion

  • Core biopsy

    All solid lumps and M3 MC get a biopsyReplaces fine needle aspiration in most cases14g spring-loaded needle gunWell toleratedMain complication is haemorrhage

  • Core biopsy - histology

    Can give grade of cancers and presence of invasion

    Can give definitive diagnosis of benign lesions - avoid surgery

  • Ultrasound vs /stereo biopsy

    Ultrasound is used for all lesions visible on ultrasound quick and accurateStereo 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

  • 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

  • VAB

    Used with either ultrasound or stereo guidanceVacuum-assisted biopsy, single needle insertion, larger sampleAllows better non-operative diagnosis, improved calc retrieval, more invasive cancer detection in DCIS

  • VAB biopsy

    11g, compared with 14g for core biopsy8g can be used to remove benign lumpsSlightly greater risk of bleedingWell toleratedCan insert clip to mark site in case lesion is totally removed

  • 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

  • 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

  • LIMITATIONS OF MAMMOGRAPHY

    As many as 5 15% of breast cancers are not detected mammographicallyA negative mammogram should not deter work-up of a clinically suspicious abnormality

  • FALSE NEGATIVES

    Causes

    Occult on mammogram (lobular CA)

    Finding obscured by dense tissue

    Technical

    Error of interpretation

  • RISK OF MAMMOGRAPHY

    Average glandular dose from a screening mammogram is extremely lowComparable risks are:

    Traveling 4000 miles by air

    Traveling 600 miles by car

    15 minutes of mountain climbing

    Smoking 8 cigarettes

  • 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

  • Detecting cancers on MRI

    Dynamic scan bolus injection of Gadolinium and rapid sequence of imagesBenign lesions can enhance Need to create a graph showing pattern of uptake over timeCancers show rapid uptake and washout

  • 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

  • Axillary node levels

    Level one:

    lateral to lat margin of pectoralis major

    Level two:

    under pectoralis minor

    Level three:

    medial and superior to pectoralis minor, up to clavicle

  • Why scan/ biopsy the axilla?

    A pre-operative diagnosis of lymph node metastases will prompt the surgeon to go straight to an axillary node CLEARANCEA negative axilla on imaging will mean the woman has either:

    Sentinel node biopsy

    Axillary sampling (four nodes)

  • 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

  • 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

  • Importance of triple assesmentMDT approachConcordanceChallenges around breast screeningA well informed patient

    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